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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diseasesofchildrOOtutt 


Lea's   Series 
of  Pocket  Text-Books. 


Diseases  of  the  Eye,  Ear 
Nose  and  Throat. 

ByW.L.  Ballen6Er,M.D.,  Lecturer 
on  Rhinology  and  Laryngology,  and 
A.  G.Wippern,  M.D.,  Clinical  Instruc- 
tor in  Diseases  of  the  Nose  and  Throat, 
College  of  Physicians  and  Surgeons, 
Chicago. 

Anatomy. 

By  Frederick  J.  Brockway,  M.D., 
Assistant  Demonstrator  of  Anatomy, 
College  of  Physicians  and  Surgeons, 
New  York. 

Bacteriology  and  Hygiene. 

By  W.  E-  Coates,  Jr.,  M.D.,  Instruc- 
tor in  Bacteriology  and  Pathology, 
College  of  Physicians  and  Surgeons, 
Chicago. 

Diagnosis. 

By  C.  P.  Collins,  M.  D.,  Attending 
Physician  to  St.  Luke's  Hospital,  New 
York. 

Physiology. 

By  H.  D.  Collins,  M.  D.,  Assistant 
Demonstrator  of  Anatomy,  and  W.  H. 
Rockwell,  Jr.,  A.  B  ,  M.D.,  Assistant 
Demonstrator  of  Anatomy,  College  of 
Physicians  and  Surgeons,  New  York. 


Gynecology. 

By  Montgomery  A.  Crockett, 
A.  B,,  M.  D.,  Adjunct  Professor  of  Ob- 
stetrics and  Clinical  Gynecology,  Med- 
ical Department, University  of  Buffalo, 
New  York. 

Obstetrics. 

By  David  J.  Evans,  M.  D.,  Demon- 
strator of  Obstetrics,  McGill  Univer- 
sity, Faculty  of  Medicine,  Montreal. 

Surgery. 

By  Bern  B.  Gallaudet,M.D.,  Dem- 
onstrator of  Anatomy,  and  Clinical 
Lecturer  on  Surgery,  College  of  Physi- 
cians and  Surgeons,  New  York. 


Dermatology. 

By  Joseph  Grindon,  M.  D.,  Pro- 
fessor of  Dermatology,  St.  Louis  and 
Missouri   Medical  College,  St.  Louis. 

Genito-Urinary  and  Venereal 
Diseases. 

By  Sylvan  H.  Likes,  M.D.,  Demon- 
strator of  Pathology  and  Genito-Uri- 
nary Surgery  at  the  College  of  Physi- 
cians and  Surgeons,  Baltimore. 

Chemistry  and  Physics. 

By  Walton  Martin,  M.  D.,  Assist- 
ant Demonstrator  of  Anatomy,  and 
William  H.  Rockwell,  Jr.,  A.  B., 
M.  D.,  Assistant  Demonstrator  of 
Anatomy,  College  of  Physicians  and 
Surgeons,  New  York. 

Practice  of  Medicine. 

By  George  E.  Malsbary,  M.  D., 
Assistant  to  the  Chair  of  Theory  and 
Practice  of  Medicine,  Medical  College 
of  Ohio,  Cincinnati. 

Histology  and  Pathology. 

By  John  B.  Nichols,  M.  D.,  Assist- 
ant in  Pathology,  Medical  Depart- 
ment, University  of  Georgetown,  and 
F.  P.  Vale,  M.  D.,  Demonstrator  of 
Normal  Histology,  Medical  Depart- 
ment, Columbian  University,  Wash- 
ington, D.  C. 

Nervous  and  Mental  Diseases. 

By  Charles  S.  Potts,  M.  D.,  In- 
structor in  Electro- Therapeutics  and 
Nervous  Diseases  in  the  University  of 
Pennsylvania,  Philadelphia. 

Materia  Medica. 

By  William  Schleif,  Ph.G.,M.D., 
Instructor  in  Pharmacy  in  the  Uni- 
versity of  Pennsylvania,  Philadelphia. 
Cloth,  $1.50,  net. 

Diseases  of  Children. 

By  George  M.  Tuttle,  M.  D.,  At- 
tending Physician  to  St.  Luke's  Hos- 
pital, Martha  Parsons'  Hospital  for 
Children  and  Bethesda  Foundling 
Asylum,  St.  Louis,   Mo. 


Fig.   I. 


Fig.    II. 


Fig.   III. 


Fig.   IV. 


The  Pathognomonic  Sign  of  Measles  (Koplik's  Spots). 


Fig.  i. — The  discrete  measles  spots  on  the  buccal  or  labial  mucous  membrane,  showing:  the 
isolated  rose-red  spot,  with  the  minute  bluish-white  centre,  on  the  normally  colored  mucous  membrane. 

Fig.  2. — Shows  the  partially  diffuse  eruption  on  the  mucous  membrane  of  the  cheeks  and  lips : 
patches  of  pale  pink  interspersed  among  rose-red  patches,  the  latter  showing  numerous  pale  bluish- 
white  spots. 

Fig.  3. — The  appearance  of  the  buccal  or  labial  mucous  membrane  when  the  measles  spots 
completely  coalesce  and  give  a  diffuse  redness,  with  the  myriads  of  bluish-white  specks.  The  exan- 
thema on  the  skin  is  at  this  time  generally  fully  developed. 

Fig.  -4.  Aphthous  stomatitis  apt  to  be  mistaken  for  measles  spots.  Mucous  membrane  normal 
in  line.     Minute  yellow  points  are  surrounded  by  a  red  area.     Always  discrete. 


Idea's  Series  of  Pocket  Text=5°°ks« 


DISEASES  OF  CHILDREN. 


A  MANUAL  FOR  STUDENTS  AND  PRACTITIONERS. 


BY 

GEORGE   M.  TUTTLE,  M.D., 

Attending  Physician  to  St.  Luke's  Hospital ;  Martha  Parson's  Hospital 
for  Children;  and  Bethesda  Foundling  Asylum,  St.  Louis. 


SERIES   EDITED  BY 

BERN    B.   GALLAUDET,   M.D., 

Demonstrator  of  Anatomy  and  Instructor  in  Surgery,  College  of  Physicians  and  Surgeons, 
Columbia  University,  New  York;  Visiting  Surgeon,  Bellevue  Hospital,  New  York. 


ILLUSTRATED  WITH  FIVE  PLATES  IN  COLORS 
AND  MONOCHROME. 


LEA   BROTHERS   &   CO., 
PHILADELPHIA    AND    NEW    YORK. 


Entered  according  to  Act  of  Congress,  in  the  year  1899,  by 

LEA   BROTHERS   &   CO., 

In  the  Office  of  the  Librarian  of  Congress,  at  Washington.    All  rights  reserved. 


WESTOOTT    &    THOMSON, 
ELECTROTYPERS,    PHILADA. 


PREFACE. 


In  preparing  this  manual  for  publication  the  author  has 
had  especially  in  view  the  requirements  of  the  beginner  in 
the  study  of  pediatrics.  His  design  has  been  to  cover  the 
subject  fully  yet  in  a  concise  form,  dealing  more  largely  with 
the  physiology  of  infancy  and  with  artificial  feeding  than  with 
the  pathological  states  found  in  childhood.  Such  diseases  as 
in  no  wise  differ  from  the  same  conditions  as  seen  in  adult 
life  have  been  but  briefly  described.  For  more  extended 
information  on  such  subjects,  or  on  those  coming  under  the 
head  of  the  so-called  "  specialties/'  the  student  is  referred 
to  more  extended  treatises. 

No  attempt  at  originality  is  professed,  and  acknowledg- 
ment is  hereby  made  of  free  reference  to  the  standard  text- 
books on  the  subject  of  pediatrics,  the  treatise  of  Holt  having 
been  most  frequently  consulted. 

The  aim  has  been  to  present  the  subject  in  a  systematic, 
orderly  form,  and  in  as  few  words  as  possible,  both  of  which 
conduce  to  ease  of  study  and  reference. 

GEORGE  M.  TUTTLE. 
St.  Louis,  Mo. 

3 


374      : 


CONTENTS. 


CHAPTER  I. 

PAGE 

The  Infant  at  Birth 17 

CHAPTER  II. 

Normal  Development  of  the  Infant     24 

CHAPTER  III. 
Examination  of  the  Child 30 

CHAPTER  IV. 

Diseases  of  the  New-born  Infant 31 

CHAPTER  V. 

Feeding  of  Infants     43 

CHAPTER  VI. 

Diseases  of  the  Digestive  System 73 

CHAPTER   VII. 
Disorders  of  Nutrition 161 

CHAPTER  VIII. 
Diseasks  ok  tiii:  Circulatory  System     17!) 

CHAPTER   IX. 
Diseasks  ok  the  Respiratory  System     210 

5 


6  CONTENTS. 

CHAPTER  X. 

PAGE 

Diseases  of  the  Genitourinary  System 257 

CHAPTER   XL 

Diseases  of  the  Nervous  System 272 

CHAPTER  XII. 

Diseases  of  the  Lymph-nodes      306 

CHAPTER  XIII. 
Diseases  of  the  Skin  .   . 311 

CHAPTER  XIV. 
Diseases  of  the  Ear 321 

CHAPTER   XV. 
Diseases  of  the  Bones 324 

CHAPTER   XVI. 
The  Infectious  Diseases 332 


DISEASES  OF  CHILDREN. 


CHAPTER   I. 

THE   INFANT   AT   BIRTH. 


RESPIRATION. 

How  established :  In  beginning  extra-uterine  life  breath- 
ing is  a  child's  first  new  function.  Previously  its  lungs  have 
been  impervious  to  air  and  to  other  than  nutritive  blood. 
Now  the  placental  circulation  is  stopped  and  the  blood  must 
pass  into  the  lungs  to  be  oxygenated.  By  the  reflex  stimuli 
of  comparatively  cold  air  on  the  skin  and  of  venous  blood 
feeding  the  respiratory  center  in  the  medulla  respiration  is 
begun,  usually  with  a  cry.  Each  breath  is  deeper  than  the 
preceding  one,  until  the  whole  lung  gradually  passes  from  a 
state  of  physiological  atelectasis  to  complete  expansion. 

External  signs :  This  change  can  be  beautifully  watched 
by  observing  the  chest-wall,  which,  being  very  elastic  and 
yielding,  will  stay  depressed,  in  inspiration,  over  unexpanded 
lung,  while  those  parts  over  expanded  lung  will  rise  and  fall 
with  the  motions  of  the  chest  in  breathing.  To  be  satisfied 
that  respiration  is  fully  established,  one  should  see  that  no 
part  of  the  chest-wall  sinks  during  inspiration. 

Rate  :  The  child  should  now  breathe  about  forty-five  times 
to  the  minute,  but  the  respiratory  rhythm  is  likely  to  be 
irregular. 

As  aids  to  effecting  natural  respiration,  slapping  the  but- 
tock-, blowing  on  the  skin,  or  alternate  applications  of  hot 
and  cold  water,  are  usually  all  that  arc  necessary. 

CIRCULATION. 
In  this  another  marked  change  occurs.     The  umbilical  vein 
and   ductus   venosus,  leading  from  the   umbilicus   to  the  in- 
2— D.  C.  17 


18  THE  INFANT  AT  BIRTH. 

ferior  vena  cava,  are  closed,  dwindling  to  a  fibrous  cord, 
the  round  hepatic  ligament,  in  two  to  five  days.  The 
Eustachian  valve,  which  guided  the  blood  from  the  right 
auricle  to  the  left  auricle,  disappears  at  once ;  the  foramen 
ovale,  through  which  the  blood  passes  from  the  right  auricle 
to  the  left  auricle,  closes  in  ten  days,  by  a  fold  of  endo- 
cardium growing  over  it  from  below ;  the  ductus  arterio- 
sus, which  carried  the  blood  from  the  pulmonary  artery  to 
the  descending  aorta,  becomes  an  impervious  cord  in  four 
to  ten  days ;  and  the  umbilical  arteries,  which  carried  the 
blood  from  the  internal  iliacs  to  the  navel,  become  the 
anterior  vesical  ligaments  above,  and  remain  as  the  superior 
vesical  arteries  below. 

The  pulse  at  birth  varies  from  140  to  120  per  minute,  and 
is  frequently  irregular.  The  higher  rate  is  found  in  girls 
and  small  infants ;  the  lower,  in  boys  and  large  infants. 

TEMPERATURE. 

At  birth  the  temperature  is  about  99°  F.  It  may  sink 
rapidly  directly  after  birth ;  but  in  a  healthy  child  it  soon 
regains  normal.  The  new-born  infant  is  naturally  very 
sensitive  to  cold,  having  lived  so  long  in  a  temperature  of 
98°  F.,  and  great  care  must  be  taken  to  prevent  chilling. 

SKIN. 

Vernix  caseosa :  The  child  at  birth  is  covered,  to  a  greater 
or  less  degree,  with  a  slippery  white  substance,  the  vernix 
caseosa,  a  mixture  of  epithelium,  down,  and  secretion  from 
the  sebaceous  glands. 

Lanugo :  In  addition  to  the  vernix  caseosa,  the  skin  shows 
an  abundant  growth  of  very  fine  downy  hairs,  the  lanugo, 
which  soon  disappears. 

Desquamation:  Shortly  after  birth  the  skin  is  frequently 
very  red,  and  later  marked  desquamation  may  occur. 

LENGTH. 

The  average  length  is  about  twenty  inches.  Below  eighteen 
inches  is  evidence  of  prematurity. 


WEIGHT— INTESTINES.  19 

WEIGHT. 

Boys  average  seven  and  a  half  pounds ;  girls,  about  seven 
pounds.  Below  five  and  a  half  pounds  shows  a  very  low 
vitality  and  suggests  prematurity. 

HEAD. 

Measurements  and  fontanelles :  The  head  measures  about 
thirteen  inches  in  circumference  in  the  occipito-frontal  line. 
The  anterior  fontanelle,  at  the  junction  of  the  coronal  and  the 
sagittal  sutures,  is  open  one  and  a  half  by  one-half  inch. 
The  posterior  fontanelle,  formed  by  the  sagittal  and  lambdoid 
sutures,  is  also  plainly  to  be  felt. 

Caput  succedaneum  :  The  head  is  apt  to  be  much  misshapen 
from  pressure  during  its  passage  through  the  pelvis,  and  on 
one  place  is  a  thick  boggy  swelling,  the  caput  succeda,neum, 
formed  by  serous  infiltration  into  the  tissues  of  the  scalp  over 
the  part  presenting  in  the  birth-canal,  and  hence  escaping 
pressure.  The  caput  disappears  in  a  few  days,  and  the  shape 
of  the  head  rights  itself  in  a  few  weeks,  both  without  assist- 
ance. 

THORAX. 

Measurements  :  The  average  circumference  of  the  chest  at 
the  nipple-line  is  thirteen  inches,  the  same  as  that  of  the 
head,  the  antero-posterior  and  transverse  diameters  being 
about  equal.  With  the  addition  of  the  shoulders,  we  have  a 
decidedly  larger  sized  body  than  the  head,  a  point  of  impor- 
ts nee  in  connection  with  the  birth  of  the  shoulders  over  the 
perineum. 

ABDOMEN. 

Here  the  average  circumference  is  about  fourteen  inches. 

INTESTINES. 

Meconium:  At  birth  the  intestines  contain  a  very  dark 
green,  pasty  substance  culled  meconium,  made  up  of  bile,  epi- 
thelium, intestinal  mucus,  and  lanugo.  This  is  voided  in 
considerable  quantities  directly  after,  and  sometimes  during 


20  THE  INFANT  AT  BIRTH. 

birth,  and,  under  the  influence  of  the  colostrum,  for  the  next 
four  days.  It  is  found  to  be  absolutely  sterile  and  free  from 
bacterial  life. 

KIDNEYS. 

Urine  :  Constantly  after  birth  the  bladder  empties  itself  of 
a  small  quantity  of  limpid  urine  of  low  specific  gravity. 

Uric  acid  and  urates :  In  the  kidneys  themselves  there  are 
deposits  of  uric  acid  and  urates,  the  so-called  infarcts,  crystals 
of  which  pass  down  the  ureters  and  are  found  as  purplish 
stains  on  the  diapers.  During  this  passage  they  may  cause 
sharp  pains.  This  is  a  frequent  cause  of  crying  in  infancy, 
and  shows  the  lack  of  sufficient  water  in  the  system. 

UMBILICAL  CORD. 

Pulsation :  The  umbilical  cord  will  be  found  to  be  strongly 
pulsating  at  birth,  and  it  is  best  to  wait  for  this  to  stop 
before  ligating.  An  exception  to  this  rule  is  made  in  con- 
gestive asphyxia,  where  the  withdrawal  of  some  blood  from 
the  child  is  desirable.  It  has  been  found  that  when  the  cord 
is  not  tied  until  after  pulsation  is  stopped  the  infant  gains 
on  an  average  of  three  ounces  of  blood,  and  its  initial  loss  of 
weight  is  lessened. 

Ligation :  The  cord  should  be  tied  two  inches  from  the 
navel,  very  tight,  with  narrow  aseptic  bobbin,  and  cut  beyond 
with  aseptic  scissors.  Before  leaving,  the  stump  should  be 
examined,  as  it  is  quite  common  to  find  it  bleeding  a  little. 
Dress  the  stump  with  dry  sterilized  gauze  or  cotton,  dusting 
with  powdered  bismuth.  Sometime  within  a  week  the  cord 
should  drop  off  by  a  process  of  dry  gangrene,  leaving  a 
healthy  ulcer  at  the  base. 

BATHING. 

After  tying  and  cutting  the  cord  the  infant  should  be 
greased  thoroughly  with  vaseline,  and  laid  aside  in  a  warmed 
woollen  blanket,  with  a  soft  towel  next  the  skin,  until  the 
mother  is  entirely  attended  to. 


EYES— CLOTHING.  21 

Then  the  baby  should  have  a  general  bath,  in  a  warm  room, 
before  an  open  fire,  if  possible,  in  water  of  a  temperature  of 
100°  F.  Castile  soap,  a  soft  sponge,  and  a  soft  towel  should 
be  the  adjuvants.  After  drying,  all  the  flexures  and  creases 
in  the  skin  should  be  dusted  with  talcum,  or  some  similar  dry 
powder. 

EYES. 

Infection  :  There  is  always  danger  of  some  form  of  infection 
to  the  conjunctivae  from  the  uterine  and  vaginal  secretions. 
It  is  therefore  wise  to  follow  the  prophylactic  treatment  intro- 
duced by  Crede,  of  first  washing  the  eyes  with  clean  water, 
or  saturated  boric  acid  solution,  and  then  instilling  a  couple 
of  drops  of  a  2  per  cent,  silver  nitrate  solution  into  each  eye, 
being  sure  that  the  lids  are  open  so  that  the  silver  reaches 
the  whole  conjunctiva,  bulbar  and  tarsal.  The  baby  should 
be  kept  in  a  darkened  room  the  first  few  days. 

Strabismus  :  It  is  well  to  remember  that  co-ordinate  move- 
ments of  the  eyeballs  are  imperfectly  performed  in  infancy 
and  hence  strabismus  is  frequently  present. 

MOUTH. 

The  mouth  should  be  freed  from  mucus,  liquor  amnii,  or 
whatever  may  have  gotten  into  it  during  birth,  by  sweeping 
the  finger,  covered  with  a  piece  of  soft  dry  gauze,  carefully 
and  gently  over  the  whole  cavity,  going  well  back  into  the 
pharynx. 

EXAMINATION  FOR  ABNORMALITIES. 

This  should  next  be  made,  with  special  attention  to  the 
skin,  mouth,  head,  spine,  hands,  feet,  genitals,  and  anus. 

CLOTHING. 

This  should  be  light,  warm,  unirritating,  and  allow  free 
movement  of  the  body  and  limbs.  A  broad  abdominal 
flannel  band  should  be  worn  the  first  four  months.  The 
other  essentials   are  a  woollen   shirt,  a   flannel  petticoat,  a 


22  THE  INFANT  AT  BIRTH. 

diaper,  and  a  dress.  For  night,  the  dress  is  exchanged  for  a 
night-gown.  Safety-pins  only  should  be  used  in  fastening 
the  clothing. 

FOOD. 

Colostrum :  Nature  prepares  no  real  food  for  the  first  three 
or  four  days,  but  during  this  time  the  breasts  of  the  mother 
secrete  colostrum,  a  thin  bluish  fluid,  showing  under  the 
microscope  the  presence  of  large  corpuscles  in  addition  to  a 
small  number  of  the  usual  fat-globules.  This  colostrum  is 
laxative  in  its  action.  Eight  or  ten  hours  after  birth  the 
baby  should  be  put  to  the  breast,  and,  after  this,  four  times 
daily  until  the  milk  comes.  This  accustoms  the  baby  to 
sucking,  reflexly  stimulates  the  uterus  to  contract,  and  hastens 
the  discharge  of  the  meconium. 

If  there  really  seems  to  be  need  of  any  food,  as  in  weakly 
infants,  a  5  per  cent,  sugar  solution  is  the  best  form  until  lac- 
tation begins.  Excessive  crying,  as  if  from  hunger,  in  a 
healthy  baby  can  usually  be  stopped  by  simply  giving  boiled 
water. 

SLEEP. 

The  child  should  sleep  almost  continuously  during  the  first 
few  days.  From  the  very  start,  training  in  good  sleeping- 
habits  should  begin,  the  baby  being  taken  up  only  to  wash 
and  to  nurse,  and  being  taught  to  go  to  sleep  when  laid 
down,  and  allowed  to  sleep  in  a  crib  by  itself.  No  walking 
nor  rocking  it,  nor  other  bad  habits,  should  be  permitted. 

PREMATURE  AND  DELICATE  INFANTS. 

Viability :  Probably  no  child  of  less  than  twenty-seven  or 
twenty-eight  weeks  of  intra-uterine  life  can  survive.  Each 
week  after  this  increases  its  chances  considerably.  In  these 
babies  the  vitality  is  very  low,  the  organs  of  digestion,  circu- 
lation, and  respiration  are  very  imperfectly  developed,  and, 
above  all  things,  the  heat-producing  function  is  very  slight. 

In  treatment  the  two  most  difficult  problems  are  to  main- 
tain the  animal  heat,  and  properly  to  nourish  them.  They 
should  not  be  clothed,  but  rather  wrapped  up  in  cotton  and 


PREMATURE  AND  DELICATE  INFANTS.  23 

then  in  blankets,  and  surrounded  constantly  by  hot  bottles, 
and  kept  in  as  nearly  as  possible  a  uniform  high  temperature. 
This  can  be  best  accomplished  in  an  incubator,  if  one  can  be 
obtained.  The  skin  should  be  thoroughly  greased  with  sweet 
oil,  and  no  bathing  should  be  allowed. 

Breast-milk  from  the  mother,  or  a  wet-nurse,  is  the  very 
best  food,  and  should  be  given  in  small  quantities,  from  one- 
half  to  three-quarters  of  an  ounce,  every  one  and  a  half  hours. 
This  maybe  given  by  a  large  medicine-dropper,  or  by  gavage, 
without  removing  the  baby  from  its  "  nest."  If  breast-milk 
cannot  be  obtained,  a  carefully  modified  diluted  cows'  milk  is 
the  next  best  food. 


CHAPTER   II. 

NORMAL   DEVELOPMENT  OF  THE   INFANT. 

WEIGHT. 

During  the  first  year  the  child  should  be  weighed  every 
week,  and  during  the  second  year  every  other  week.  The 
gain  or  loss  in  weight  from  one  weighing  to  another  is  the 
very  best  indication  we  have  of  the  general  welfare  of  the 
child.  Frequently  the  first  signal  of  beginning  trouble  is  the 
absence  of  the  regular  weekly  gain,  or  the  presence  of  a  slight 
loss. 

Physiological  loss :  During  the  first  three  days  of  life  there 
is  a  so-called  physiological  loss  in  weight,  averaging  about  ten 
ounces.  This  is  due  to  loss  of  urine,  meconium,  and  vernix 
caseosa,  and  the  lack  of  food  the  first  few  days.  With  the 
advent  of  milk  in  the  mother's  breasts  the  normal  gain  begins, 
and,  by  about  ten  days,  the  birth-weight  should  be  regained. 

At  six  months  the  birth-weight  is  about  doubled,  and  at  the 
end  of  a  year  about  trebled.  During  the  first  six  months  the 
gain  should  average  four  to  eight  ounces  per  week ;  and  from 
two  to  four  ounces  during  the  second  six  months.  From  four 
to  six  pounds  per  year  is  about  an  average  gain  for  the  next 
ten  years. 

Sickness  of  any  kind,  and  particularly  digestive  disturb- 
ances, stop  the  normal  gain,  and  usually  substitute  a  loss. 
Even  the  physiological  process  of  dentition  is  accompanied  by 
a  diminished  weekly  gain. 

HEIGHT. 

During  the  first  year  the  growth  is  about  eight  inches, 
an  average  of  two-thirds  of  an  inch  per  month,  the  increase 
being  somewhat  greater  during  the  first  quarter.  During 
the  second  year  the  growth  is  about  four  inches,  and  during 

24 


HEAD— MUSCULAR  ACTS.  25 

the  next  ten  years  it  averages  about  two  inches  per  year. 
This  growth,  in  infancy,  takes  place  more  rapidly  in  the 
extremities  than  in  the  trunk,  although  at  birth  the  trunk 
was  relatively  longer  than  the  limbs. 

HEAD. 

During  the  first  year  the  occipito-frontal  circumference  of  the 
head  should  increase  about  four  inches,  and  about  one  inch 
more  during  the  second  year.  A  gain  of  an  inch  and  a  half 
more  should  take  place  by  the  fifth  year,  at  which  time  the 
head  attains  its  adult  size. 

The  cranial  sutures  ossify  by  the  sixth  month,  the  posterior 
fontanelle  closing  by  the  second  month,  but  the  anterior  not 
till  the  eighteenth  month,  having  increased  some  in  size 
during  the  first  nine  months.  Early  closing  fontanelles  and 
sutures  suggest  premature  ossification,  or  cerebral  defects ; 
while  fontanelles  and  sutures  remaining  open  over  time  are 
suggestive  of  rickets  or  hydrocephalus. 

THORAX. 

The  thorax  grows  more  transversely  than  from  before  back- 
ward, keeping  pace  with  the  growth  of  the  head,  and  not 
until  the  third  year  is  it  distinctly  larger  than  the  head.  A 
chest  of  a  three  years'  child  not  larger  than  its  head  points  to 
extreme  delicacy. 

ABDOMEN. 

The  abdomen  at  birth  is  larger  than  both  head  and  chest ; 
at  two  years  it  should  be  about  the  same  size,  and  afterward 
the  smallest  of  the  three. 

MUSCULAR  ACTS. 

Voluntary,  but  inco-ordinate  muscular  movements  are 
made  about  the  fourth  month.  The  head  is  held  erect  about 
the  same  time.  The  child  sits  erect  about  the  seventh  month. 
The  first  attempts  at  walking  are  made  about  the  twelfth  to 
the  fifteenth  month,  some  children  learning  to  creep  three  or 
four  months  earlier. 


26  NORMAL  DEVELOPMENT  OF  THE  INFANT. 

PULSE. 

The  force  and  rhythm  in  infancy  are  the  important  factors 
rather  than  the  rate.  During  the  first  year  the  frequency 
varies  from  110  to  140,  reaching  100  by  the  end  of  the 
second  year.  By  the  eighth  year  the  adult  rate  is  present. 
The  rate  is  markedly  influenced  by  very  trivial  causes,  such 
as  crying,  struggling,  or  excitement,  making  its  value  unim- 
portant. It  is  helpful  to  remember  that  the  pulse  can  be 
easily  counted  in  the  anterior  fontanelle. 

RESPIRATION. 

Respiration  is  chiefly  abdominal,  and  the  rapidity  very 
variable.  During  sleep  it  averages  considerably  less  than 
during  wakefulness.  The  rate  in  the  first  months  is  thirty- 
five  to  forty;  during  the  second  year  it  falls  to  twenty-eight; 
during  the  third,  to  twenty-five ;  and  by  puberty  it  reaches  the 
adult  rate,  eighteen  to  the  minute. 

In  health,  the  rhythm — inspiration,  expiration,  pause — is 
unchanged.  The  ratio  between  pulse  and  respiration  is  about 
three  and  a  half  to  one. 


TEMPERATURE. 

After  the  more  or  less  marked  fall  succeeding  birth  the 
temperature  immediately  assumes  the  adult  range,  the  main 
point  to  be  kept  in  mind  being  the  extreme  fluctuations 
under  slight  causes,  the  heat-centres  being  very  unstable. 
In  the  chronic  wasting  diseases  a  subnormal  temperature  is 
quite  common. 

DENTITION. 

At  birth  the  teeth  are  enclosed  in  the  dental  sacs  in  the 
alveoli  of  the  jaws,  and  their  growth  is  upward  by  calcifi- 
cation of  their  roots,  this  growth  beginning  at  birth. 

The  milk  or  deciduous  teeth  are  twenty  in  number,  and  are 
cut  in  the  following  order,  although  quite  wide  variations  are 
frequent : 

1 .  Two  lower  central  incisors,  at  six  to  nine  months ;  2. 


URINE.  27 

Four  upper  incisors,  at  eight  to  twelve  months ;  3.  Two 
lower  lateral  incisors  and  four  anterior  molars,  at  twelve  to 
fifteen  months  ;  4.  Four  canines,  at  twelve  to  fifteen  months  ; 
5.  Four  posterior  molars,  at  twenty-four  to  thirty  months. 

Early  teething  usually  means  early  ossification  of  the 
cranial  bones ;  and  late  teething  usually  means  rickets,  or 
other  form  of  malnutrition. 

In  a  healthy  child  dentition  is  usually  not  accompanied  by 
any  constitutional  disturbance,  the  tooth  very  gradually 
forcing  its  way  through  the  overlying  gum  by  a  process  of 
pressure-absorption,  first  showing  its  presence  as  a  lump 
under  the  reddened  mucous  membrane,  this  growing  whiter 
as  the  tooth  nears  the  surface. 

If  any  symptoms  are  present,  they  are  only  restlessness, 
fretf ulness,  disturbed  sleep,  salivation,  a  disposition  to  put 
objects  into  the  mouth,  and  possibly  a  little  fever. 

In  previously  unhealthy  children  more  serious  symptoms 
may  coincide  with  dentition,  such  as  vomiting,  diarrhoea, 
fever,  earache,  eczematous  eruptions,  and  possibly  con- 
vulsions; but  there  is  always  the  question  whether  the  un- 
healthy condition  as  a  predisposing  factor  is  not  more  of  a 
cause  of  the  symptoms  than  the  teething.  The  more  care- 
fully other  causes  are  looked  for,  the  fewer  cases  due  to 
dentition  only,  even  in  these  susceptible  infants,  will  be 
found.  Rarely,  a  case  calling  for  lancing  the  gums  will  be 
discovered. 

The  second  or  permanent  teeth  are  cut  as  follows  :  1.  First 
four  molars,  at  six  years  ;  2.  Eight  incisors,  at  seven  to  eight 
years;  3.  Eight  tricuspids,  at  nine  to  ten  years;  4.  Four 
canines,  at  twelve  to  fourteen  years  ;  5.  Second  four  molars,  at 
twelve  to  fifteen  years ;  6.  Third  four  molars  at  seventeen  to 
twenty-five  years.  Except  for  the  first  four  molars  the  order 
is  about  the  same  as  for  the  first  set.  In  growing,  the  second 
set  cause  atrophy  of  the  roots  of  the  first  set  until  they  loosen 
and  fall  out. 

URINE. 

For  obvious  reasons  accurate  results  as  to  quantity  of  urine 
in  infancy  are  hard  to  obtain.     During  the  first  few  days  of 


28  NORMAL  DEVELOPMENT  OF  THE  INFANT. 

life  the  daily  quantity  is  three  ounces ;  by  two  months  it  in- 
creases to  eight  to  ten  ounces ;  by  six  months  to  ten  to  six- 
teen ounces ;  by  two  years  to  twenty  ounces ;  by  five  years 
to  twenty-six  ounces ;  by  eight  years  to  forty  ounces  ;  and  by 
fourteen  years  to  forty-eight  ounces.  The  specific  gravity 
averages  from  1005  to  1010.  The  reaction  is  acid.  Traces 
of  albumin  or  of  sugar  may  be  found  during  certain  periods, 
but  rapidly  disappear. 


THE  F.ECES. 

These  partake  of  the  characteristics  of  meconium  for  four 
or  five  days,  when  they  change  to  milk-stools.  These  are 
yellow,  of  the  consistence  of  semi-solid  butter,  smooth, 
of  acid  reaction,  and  inodorous.  The  gases  present  are 
hydrogen  and  carbonic  acid.  The  fasces  amount  to  about 
three  ounces  per  day  in  quantity,  and  are  passed  from  two  to 
four  times  daily.  Chemically  they  consist  of  85  per  cent,  of 
water,  and  of  fat,  proteids,  lactic  acid,  salts,  and  bile-ele- 
ments. Bacteria  are  present  in  large  variety,  especially  the 
bacillus  coli  communis.  Stools  resulting  from  cows'  milk  are 
whiter,  from  the  presence  of  more  curds.  When  the  child 
begins  a  mixed  diet  the  stools  assume  the  adult  type. 

SPECIAL  SENSES. 

Sight :  This  is  present  from  birth,  but  the  eyes  are  very 
sensitive  to  light,  and  not  till  the  fourth  month  do  they  seem 
to  be  used  voluntarily. 

Hearing :  Deafness  is  present  for  a  day  or  two.  This  is 
probably  due  to  the  absence  of  air  from  the  tympanum,  but 
when  respiration  is  well  established  the  hearing  begins,  and 
later  becomes  quite  sharp.  The  infant  does  not  seem  to 
locate  sounds  before  the  fourth  month. 

Touch :  Sensation  is  present,  but  is  dull  for  three  months. 
It  is  highly  developed  in  the  tongue  and  lips,  where  the  tem- 
perature-sense is  also  acute. 


SPECIAL  SENSES.  29 

Taste  :  This  sense  is  highly  developed  from  birth. 

Smell :  We  know  scarcely  anything  about  this  sense. 

Speech :  This  function  is  very  variable  in  its  development. 
Very  much  depends  on  efforts  at  training,  as  institution- 
children  always  talk  much  later  than  those  brought  up  at 
home.  By  the  end  of  the  first  year  the  child  should  begin 
to  say  a  few  words,  and  by  the  end  of  the  second  year  should 
form  a  few  sentences.  If  there  has  been  no  effort  at  speak- 
ing by  the  end  of  two  years,  probably  some  mental  defect  is 
present  or  "  deaf-mutism  "  may  be  suspected. 


CHAPTER    III. 

EXAMINATION   OF   THE   CHILD. 

History :  First  obtain  a  careful  account  of  the  family  his- 
tory, and  then  the  personal  history  of  the  child.  Then 
gather  together  systematically  all  the  facts  about  the  present 
illness,  willingly  listening  to  all  the  ideas  and  observations  of 
the  mother  or  nurse  about  the  child.  Always  inquire  about 
the  food  and  as  to  any  drugs  which  may  have  been  taken. 

Inspection :  A  careful  observation  of  the  child  is  next 
necessary,  trying  to  disturb  it  as  little  as  possible.  Notice 
the  position,  whether  it  is  natural  and  easy ;  the  character  of 
the  sleep;  the  respiration;  the  skin,  its  color  and  whether 
dry  or  moist ;  the  facial  expression ;  the  nostrils,  whether 
quiet  or  moving ;  the  cough,  and  if  present  its  character  ;  the 
cry  ;  the  mental  condition  ;  the  mouth,  whether  it  is  kept  open 
or  closed  in  breathing ;  the  condition  of  the  eyes  and  pupils  ; 
the  presence  or  absence  of  enlarged  lymph-glands  ;  the  pres- 
ence or  absence  of  muscular  movements  or  twitching s ;  the 
presence  of  any  discharges.  Compare  any  of  these  as  found 
with  the  condition  in  a  normal  infant. 

Physical  Examination  :  First  take  the  temperature,  by  rectum 
if  possible,  as  it  is  very  hard  to  get  by  mouth,  and  the  axil- 
lary temperature  is  uncertain.  Then  take  the  pulse,  usually 
at  the  same  time,  remembering  the  comparative  unimportance 
of  its  rate.  Next  strip  the  child,  and  examine  the  skin  care- 
fully for  rashes.  Auscultate  and  percuss  the  heart  and  lungs 
carefully.  Palpate  the  abdomen,  remembering  that  normally 
the  liver  reaches  below  the  free  border  of  the  ribs,  and  that 
the  spleen  cannot  be  felt.  Inspect  the  genitals.  Examine  the 
muscular  development.  Examine  the  bones,  then  the  extremi- 
ties and  the  ribs.  Investigate  the  development  of  the  ner- 
vous system,  and  the  functions  dependent  on  it.  Examine  the 
fontanelle,  and  if  open  see  if  it  is  bulging,  flat,  or  depressed. 
Lastly  examine  minutely  the  ears,  the  mouth,  and  the  throat. 

30 


CHAPTER    IV. 
DISEASES  OF  THE  NEW-BORN  INFANT. 

ASPHYXIA. 

Forms :  There  are  two  distinct  forms  of  asphyxia  after 
birth — (1)  the  congestive,  and  (2)  the  anaemic.  In  the  first, 
the  child  is  livid  in  color,  appears  swollen,  and  has  good  mus- 
cular tone  and  a  full,  strong  pulse.  In  the  second  form  the 
skin  is  pale,  the  muscles  flaccid,  and  the  pulse  inappreciable. 

Prognosis :  The  prognosis  in  the  congestive  variety  is  far 
better  than  in  the  anaemic. 

Asphyxia — treatment :  This  is  simple  in  the  former ;  first 
allowing  a  little  blood  to  escape  from  the  cut  cord  to  reduce 
the  internal  congestion,  and  then  alternately  dipping  the  baby 
into  hot  (110°  F.)  and  cold  water.  The  reflexes  being  still 
present,  the  response  is  marked. 

In  the  latter  variety  allow  the  child  to  get  as  much  blood 
as  possible  from  the  placenta,  and  then  perform  artificial  res- 
piration, for  a  very  long  time  if  necessary,  at  the  rate  of  ten 
to  fifteen  times  per  minute.  Sylvester's  method  is  undoubt- 
edly the  best,  as  the  baby  can  be  kept  in  a  tub  of  hot  water 
during  the  manipulations.  Be  sure  that  the  mouth  and 
pharynx   are   clear  of   any   foreign   substance. 

In  some  cases  where  artificial  respiration  fails,  direct  infla- 
tion of  the  lungs,  by  the  mouth-to-mouth  method,  or  by  pass- 
ing a  catheter  into  the  larynx,  succeeds.  In  these  cases,  after 
respiration  is  established  attention  is  necessary  for  some  time 
to  pic  vent  relapses  and  to  be  sure  that  atelectasis  is  over- 
come 

ICTERUS. 

This  common  affection,  of  still  unknown  origin,  appears 
from  the  second  to  the  tilth  (lav  and  lasts  about  a  week.  It 
occurs  in  about  one-third  of  new-born  infants.      It  is  prob- 

31 


32  DISEASES  OF  THE  NEW-BORN  INFANT. 

ably  hepatogenous  in  origin,  and  due  to  resorption  of  bile- 
pigment.     It  requires  no  treatment,  disappearing  easily. 

In  some  cases  an  early  jaundice  increases  in  intensity  and 
presents  constitutional  symptoms.  In  these  cases  the  prog- 
nosis is  bad,  aud  there  is  usually  either  a  septic  infection  from 
the  umbilical  vessels  or  a  congenital  malformation  of  the 
bile-ducts. 

OPHTHALMIA. 

Definition :  This  is  an  infectious  conjunctivitis,  in  the  major- 
ity of  the  cases  due  to  the  gonococcus,  less  frequently  to  the 
ordinary  pyogenic  germs.  All  grades,  from  a  mild  conjunc- 
tivitis to  chemosis,  corneal  ulceration,  and  sloughing,  may 
occur. 

Symptoms :  Redness,  swollen  lids,  copious  purulent  dis- 
charge, pain,  and  photophobia. 

Ophthalmia — treatment :  Prophylaxis,  as  already  described, 
is  most  important.  If  the  disease  is  started,  frequent  and 
thorough  cleansing  with  a  saturated  boric  acid  solution,  or  a 
1  :  5000  bichloride  of  mercury  solution,  is  necessary.  Twice 
a  day  a  few  drops  of  a  1  per  cent,  silver  nitrate  solution  should 
be  instilled  in  the  eyes,  and  in  the  intervals  ice-cold  com- 
presses, frequently  changed,  should  be  kept  on  the  lids.  It 
is  always  wise  to  call  in  the  services  of  an  oculist. 

CEREBRAL  HEMORRHAGE. 

Source  :  A  quite  frequent  accompaniment  of  birth  is  some 
form  of  bleeding  in  the  skull,  which  is  regularly  from  the 
congested  vessels  of  the  pia  mater.  These  hemorrhages  are 
mostly  mechanical,  and  are  seen  in  prolonged  non-instru- 
mental births  quite  as  frequently  as  after  the  use  of  forceps. 
The  hemorrhage  is  situated  usually  on  the  base,  and  nearer 
the  back  than  the  front  of  the  brain.  They  occur  in  both 
breech  and  vertex  cases. 

Cerebral  hemorrhage — symptoms :  If  large,  the  baby  is 
often  stillborn.  If  smaller,  asphyxia,  torpor,  irregular 
respiration,  feeble,  slow  pulse,  and  convulsions  are  the  regular 
symptoms.     The  pupils  are  variable,  but  oscillatory  move- 


CEFHALE rMM ATOM  A— OBSTETRICAL  PARALYSES.      33 

ments  of  the  eyeballs  are  frequent.  According  to  the  size 
and  location  of  the  clot,  localized  paralysis  or  complete 
hemiplegia  is  present.  In  the  surviving  cases  permanent 
damage  to  the  brain  and  its  supplied  parts  is  left,  the  symp- 
toms depending  on  the  location  of  the  lesion,  such  as  idiocy, 
epilepsy,  monoplegia,  diplegia,  or  hemiplegia. 

Cerebral  hemorrhage — treatment :  This  is  almost  entirely 
preventive  by  shortening  long  labors  by  the  judicious  use  of 
the  forceps.  For  the  changes  left  behind  by  these  accidents 
very  little  can  be  done. 

CEPHALHEMATOMA. 

Definition  :  This  is  an  extravasation  of  blood  under  the  peri- 
cranium, and  due  to  some  traumatism  during  labor.  The 
tumor  is  always  limited  by  the  attachment  of  the  pericranium, 
never  passing  over  a  suture  or  fontauelle.  It  appears  from 
the  first  to  the  fourth  day,  and  grows  gradually  for  about  a 
week,  when  it  slowly  disappears.  It  is  fluctuating,  and  shows 
none  of  the  signs  of  inflammation.  As  it  grows  older  there  is 
a  raised  ridge  around  the  margin  due  to  organization  of  the 
effused  blood,  and  giving  the  impression  of  a  depression  of 
the  skull  inside  this  ridge.  If  the  scalp  is  lacerated,  infec- 
tion is  likely  to  occur,  followed  by  abscess.  The  whole  tumor 
will  disappear  in  two  or  three  months  by  a  process  of  absorp- 
tion, unless  some  accident  happens  to  it. 

Cephalhematoma — treatment :  Care  should  be  exercised  to 
protect  the  part  from  injury,  and  to  keep  aseptic  any  abrasions 
of  the  skin  in  the  neighborhood.  Non-interference  is  other- 
wise the  proper  course.     If  an  abscess  forms,  open  and  pack. 

OBSTETRICAL  PARALYSES. 

Tin'  two  commonest  forms  of  this  condition  are  (1)  facial, 
and  (2)  brachial,  paralysis.  The  former  (1)  is  due  to  pressure 
i»n  the  facial  nerve  by  one  of  the  blades  of  the  forceps.  The 
eye  on  the  paralyzed  side  remains  open,  and  in  moving  the 
face  tlii-  side  i-  found  to  be  smooth,  and  the  mouth  is  drawn 
to  the  sound  side. 
3-D.  c. 


34  DISEASES   OF  THE  NEW-BORN   IMA  ST. 

Facial  paralysis — treatment :  None  is  needed,  as  the  condi- 
tion usually  disappears  within  a  week.  In  those  eases  where 
no  improvement  appears  within  a  month  regular  electrical 
treatment  should  be  given. 

In  (2)  brachial,  also  called  Erb's,  paralysis  one  or  more 
groups  of  muscles  of  the  upper  extremity  are  paralyzed. 
Here  also  the  cause  is  usually  traumatism  from  the  forceps  or 
from  pulling  on  the  arm,  or  in  the  axilla.  The  muscles  most 
often  affected  are  the  deltoid,  biceps,  brachialis  anticus,  supi- 
nator longus,  and  the  supra-  and  infra-spinatus.  The  arm 
hangs  flaccid,  and  after  some  time  the  muscles  atrophy. 

Brachial  paralysis — treatment :  Most  of  these  cases  also 
recover  spontaneously  in  a  few  months,  but  this  can  be  has- 
tened by  electrical  treatment.  Strychnine  is  a  useful  drug  in 
both  forms. 

SEPSIS. 

Sepsis  in  the  newly  born  is  present  in  a  great  variety  of 
manifestations.  The  infection  by  pyogenic  bacteria  commonly 
takes  place  through  the  umbilical  wound,  but  any  abrasion  of 
the  skin  or  mucous  membranes  presents  an  avenue  of  invasion. 

Sepsis — symptoms :  These  vary  from  those  of  a  slight  local 
infection  to  a  general  severe  or  fatal  septicaemia ;  from  an 
omphalitis,  an  umbilical  phlebitis,  or  a  peritonitis,  to  a  strep- 
tococcal inflammation  localized  in  almost  any,  or  more  than 
one,  of  the  important  organs,  such  as  the  lungs,  pleura,  peri- 
or  endo-cardium,  meninges,  bones,  joints,  stomach,  intestines, 
or  the  cellular  tissues.  The  general  symptoms  are  irregular 
fever  and  its  concomitants,  rapid,  feeble  pulse,  wasting,  stupor 
alternating  with  restlessness,  diarrhoea,  and  vomiting.  Hem- 
orrhages are  frequent,  and  it  is  in  these  cases  that  the  severe 
forms  of  jaundice  occur. 

Sepsis — treatment:  Prophylaxis  is  most  important  in  the 
aseptic  care  of  the  navel  and  of  any  abrasions  of  the  skin. 
After  the  disease  has  started  any  local  symptoms  should  be 
treated  as  usual,  and  in  addition  a  general  supportive  and 
stimulating  treatment  should  be  followed- — in  other  words, 
proper  food  and  whiskey. 


TETA  N  US—MELJENA .  35 


TETANUS. 


Definition  :  This  is  an  infectious  disease,  caused  by  a  specific 
germ,  and  is  characterized  by  tonic  muscular  spasms  affect- 
ing earlv  the  muscles  of  the  jaw,  but  later  all  the  muscles 
of  the  body.  The  infection  usually  occurs  by  the  navel,  but 
other  sources  may  allow  its  entrance. 

Tetanus — symptoms:  These  begin  usually  about  the  time  of 
the  separation  of  the  cord,  with  rigidity  of  the  jaws  and  conse- 
quent difficulty  in  nursing.  Later,  the  body  becomes  rigid  at 
intervals,  complete  relaxation  taking  place  between  spasms. 
This  spastic  condition  is  easily  brought  on  by  any  external 
irritant,  such  as  noise  or  jarring,  the  reflexes  being  markedly 
increased.  Later,  general  tonic  spasms  with  opisthotonos 
supervene.  The  temperature  varies  from  101°  to  106°  F. 
Death  is  caused  by  exhaustion  or  stoppage  of  the  respiration. 

Prognosis  :  It  is  a  very  fatal  disease,  the  mortality  being 
from  90  to  95  per  cent. 

Tetanus — treatment:  Prophylaxis  by  surgical  cleanliness 
in  the  care  of  the  cord,  or  any  wounds,  is  most  important. 
In  actual  cases  the  patient  should  be  kept  deeply  under  the 
influence  of  chloral  and  bromide,  they  being  pushed  to  their 
physiological  limit.  Absolute  quiet  of  the  patient  should  be 
enforced.  Feeding  by  a  catheter  through  the  nose  may  be 
necessary.  Of  late  years  a  tetanus  antitoxin  has  been  used 
with  seemingly  good  results,  when  given  early  enough. 

EPIDEMIC  HEMOGLOBINURIA. 

Winckel  first  described  this  disease  in  1879.  Its  essential 
symptoms  are  hemoglobinuria,  with  cyanosis  and  icterus, 
occurring  in  epidemics.  The  disease  begins  three  or  four 
days  after  birth,  and  death  takes  place  in  about  two  days. 
It  is  very  fatal,  and  should  probably  be  classed  under  the 
head  of  Sepsis.     Treatment   is  of  no  avail. 

MELENA. 
Definition:    By  this   term    is   meant   hemorrhage   from    the 
stomach  <>r    intestines,  a    no1   infrequent    occurrence  shortly 
after  birth,   but  of  varying  degrees  of  intensity. 


36  DISEASES  OF  THE  NEW-BORN  INFANT. 

Symptoms  :  These  gastro-enteric  hemorrhages  begin  usually 
during  the  first  few  days  of  life.  The  blood  is  light  colored 
when  passed  fresh,  or  dark  when  partially  digested.  Asso- 
ciated with  this  hemorrhagic  diathesis  there  may  be  bleedings 
under  the  skin,  into  the  kidneys,  or  from  the  vagina  or  navel, 
or  any  of  these  forms  may  occur  independently. 

Prognosis :  This  is  serious,  but  not  always  fatal,  depending 
on  the  extent  of  the  bleeding  and  the  vitality  of  the  child. 
Of  late  there  is  some  evidence  of  this  condition  also  being 
an  infection,  and  entering  through  the  digestive  tract. 

Melaena — treatment :  Ergot  is  the  drug  recommended,  but 
its  efficacy  is  doubtful.  Special  attention  to  the  general 
nutrition  is  more  important,  and  washing  the  bowels  and 
stomach  with  a  cleansing  astringent  solution  should  be  tried. 
External  hemorrhages  are  treated  by  local  astringents. 

PEMPHIGUS. 

This  form  of  bullous  eruption  is  often  found  on  new-born 
babies. 

There  are  two  general  varieties  which  are  very  important 
to  differentiate  : 

First,  the  form  occurring  as  one  of  the  manifestations  of 
congenital  syphilis. 

The  diagnosis  rests  on  the  presence  of  other  lesions  of  the 
disease,  on  the  presence  of  bulla?  on  the  palms  and  soles,  and 
on  the  history  of  the  parents. 

Second,  there  is  a  form  consisting  almost  entirely  of  bullce 
located  on  various  parts  of  the  body,  the  trunk  especially, 
which  seems  to  be  infectious  in  its  nature.  This  latter  form 
heals  well  under  the  application  of  drying  antiseptic  powders 
and  cleanliness. 

GRANULOMA  OF  UMBILICUS. 

This  is  a  little  lump  of  granulations  left  after  the  slough- 
ing of  the  cord,  and  causing  a  purulent  discharge.  At  times 
there  may  be  associated  with  it  a  patent  urachus  leading  to 
the  bladder,  and  hence  a  few  drops  of  urine  may  ooze  from 
the  navel. 


UMBILICAL  HERNIA— SCLEREMA.  37 

Treatment :  It  is  best  snipped  off  by  scissors  and  the  base 
touched  with  solid  nitrate  of  silver. 

UMBILICAL  HERNIA. 

This  form  of  rupture  usually  appears  through  the  opening 
in  the  linea  alba  for  the  umbilical  vessels,  and  before  the 
vessels,  and  before  the  third  month  of  life.  It  varies  in  size 
from  a  simple  convexity  of  the  navel  to  a  tumor  large 
enough  to  become  strangulated. 

Umbilical  hernia — treatment :  A  mechanical  application  is 
usually  all  that  is  required,  the  main  care  being  to  prevent 
the  formation  of  a  rupture  by  wearing  an  abdominal  band 
during  the  first  four  months.  If  the  hernia  is  present,  it  is 
best  held  back  by  rubber  strapping  around  the  abdomen  with 
an  ordinary  wooden  button  over  the  ring,  acting  as  a  pad  to 
prevent  protrusion.  If  this  is  worn  constantly  for  three  to 
six  months,  the  hernia  is  regularly  cured. 

MASTITIS. 

A  slight  degree  of  inflammation  of  the  breasts  is  fairly 
common  in  new-born  infants  of  both  sexes. 

Symptoms :  These  are  pain,  tenderness,  and  secretion  of 
small  quantities  of  a  milky  fluid. 

Etiology  :  Traumatism  and  lack  of  cleanliness. 

Treatment :  Apply  cool,  clean  compresses,  and  do  not  rub 
nor  squeeze  the  breasts.  They  may  be  painted  with  tincture 
of  belladonna  if  the  inflammation  is  severe. 

SCLEREMA. 

This  is  a  condition  of  hardening  of  the  skin  and  subcu- 
taneous tissues  in  circumscribed  areas,  or  more  generally.  It 
occurs  in  feeble,  badly  nourished  babies,  and  is  usually 
fatal.  The  condition  is  associated  with  marked  lowering  of 
the  cutaneous  temperature  of  the  body,  and  is  probably  the 
result  c\'  the  hardening  of  the  subcutaneous  fat,  duv  to  this 
low  temperature.     There  is  no  pitting  on  pressure. 

Treatment:  Artificial  heal  and  proper  nutrimenl  are  all  we 
can  do  tor  these  cases.      Use  of  the  incubator  is  indicated. 


38  DISEASES  OF  THE  NEW-BORN  INFANT. 

HYDROCEPHALUS. 

Varieties :  This  condition,  of  water  on  the  brain,  is  of  two 
varieties,  external  and  internal. 

The  former,  in  which  the  fluid  is  between  the  brain  and 
dura  mater,  in  the  arachnoid,  is  quite  rare.  The  latter,  with 
the  fluid  in  the  cerebral  ventricles,  is  the  common  form.  The 
condition  may  be  congenital,  or  more  rarely  acquired. 

Hydrocephalus — etiology :  The  cause  is  a  mechanical  one, 
producing  exudation  by  pressure,  or  is  due  to  a  chronic  in- 
flammation of  the  lining  membrane  of  the  ventricles.  The 
fluid  resembles  cerebro-spinal  fluid  in  character,  and  may  be 
present  in  quantities  up  to  two  quarts  or  more.  The  ven- 
tricles are  dilated,  and  the  brain  is  thinned  by  pressure,  at 
times  to  a  mere  shell. 

Hydrocephalus — symptoms  :  The  cranial  sutures  are  widely 
open,  even  those  at  the  base  in  marked  cases.  The 
fontanelles  are  open  and  bulging,  the  head  is  enlarged,  the 
forehead  is  high,  and  the  face  seems  small.  Fluctuation  and 
even  translucency  can  be  obtained  in  marked  cases.  The 
head  cannot  be  held  up,  the  mental  condition  is  dull,  and  there 
is  a  general  lax  state  of  the  muscles,  although  there  may  be 
localized  rigidity.  Nystagmus,  strabismus,  and  inability  to 
close  the  upper  lid  over  the  eyeball  are  often  present.  Con- 
vulsions may  occur. 

When  the  head  enlarges  greatly  in  utero  birth  may  be  im- 
possible without  perforation. 

Prognosis :  Recovery  is  rare.  When  the  process  ceases 
and  the  child  grows  up  some  mental  defect  is  usually  present. 

Hydrocephalus — treatment :  This  is  very  unsatisfactory. 
Iodide  of  potassium  to  cause  absorption  may  be  tried. 
Various  operative  procedures  have  been  used,  and  aspiration 
is  probably  the  best  of  them  ;  but  all  are  of  doubtful  value. 

MENINGOCELE. 

Definition:  This  means  a  protrusion  of  some  part  of  the 
membranes  of  the  brain  through  a  hole  in  the  cranial  wall, 
usually  in  the  location  of  a  suture  or  fontanelle.     The  tumor 


SPINA   BIFIDA— HARELIP— CLEFT  PALATE.  39 

is  filled  with  fluid  communicating  with  that  in  the  brain,  and 
frequently  brain-elements  are  also  present. 

Symptoms :  The  tumor  fluctuates,  and  is  most  often  seated 
in  the  occipital  region  or  at  the  root  of  the  nose.  The  child 
usually  has  other  deformities  associated. 

Meningocele — treatment :  Aspiration  and  the  injection  of 
tincture  of  iodine  should  first  be  tried.  A  plastic  operation 
may  be  necessary. 

SPINA  BIFIDA. 

Definition :  This  is  a  protrusion  of  the  spinal  meninges 
through  the  unclosed  lamina?  of  one  or  more  of  the  vertebrae. 
In  the  sac  of  membranes  is  usually  some  portion  of  the  spinal 
cord.  The  tumor  is  covered  by  skin  to  near  the  apex,  when 
the  covering  becomes  parchment-like  and  easily  ulcerates. 

Spina  bifida — symptoms:  The  tumor  is  present  at  birth, 
and  usually  is  situated  in  the  lumbar  region.  It  fluctuates ; 
and  if  the  baby  cries,  as  the  intracranial  pressure  is  increased 
it  enlarges.  If  the  cord-elements  are  in  the  sac,  paralysis  of 
legs  and  of  the  bladder  and  rectum  is  present.  The  tumor 
has  a  tendency  to  grow,  and  eventually  to  ulcerate  and 
burst,  when  death  from  infection  usually  follows. 

Prognosis  :  If  no  paralysis  coexist,  complete  recovery  may 
occur.     If  paralysis  is  present,  the  prognosis  is  bad. 

Spina  bifida — treatment :  Protect  the  tumor  from  pressure 
and  trauma.  Attend  to  the  rectum  and  bladder.  Aspiration 
with  injection  of  tincture  of  iodine  is  the  best  operative  pro- 
cedure.    A  plastic  operation  may  be  made. 

HARELIP    CLEFT  PALATE. 

Definition  :  This  abnormality  is  due  to  imperfect  closure  of 
the  maxillary  and  intermaxillary  processes  in  embryonal  life. 
The  fissure  may  be  single  or  double,  and  may  involve  the  lip 
only,  or  the  intermaxillary  bono,  or  the  soft  or  hard  palate, 
or  nil.  The  deformity  is  unsightly  and  prevents  the  infant 
sucking  with  ease. 

Harelip  and  cleft  palate — treatment :  H<<li<-<tl  care  is  to  feed 
with  :i  spoon,  or  dropper,  or  gavage  if  necessary  ;  to  keep  the 
mouth  scrupulously  clean.     Surgically  the   fissures   may  be 


40  DISEASES  OF  THE  NEW-BORN  INFANT. 

closed  by  operation  ;  or  the  cleft  palate  by  a  dental  plate.  In 
operating  for  harelip  the  second  or  third  month  is  the  proper 
time,  and  for  cleft  palate  the  third  or  fourth  year. 

OTHER  DEFORMITIES. 

Clubfoot :  This  deformity,  usually  of  the  equino-varus 
variety,  is  often  congenital.  It  belongs  to  the  province  of 
the  orthopedic  surgeon,  but  is  mentioned  here  to  call  atten- 
tion to  the  importance  of  immediate  treatment,  the  earlier 
the  better.  By  massage,  manipulation,  and  a  simple  appara- 
tus the  parts  can  usually  be  brought  back  to  their  normal 
relations  in  the  early  weeks  of  life,  when  later  complicated 
apparatus  and  surgical  operations  would  be  necessary. 

Imperforate  rectum :  This  anomaly  is  fairly  frequent,  and 
is,  of  course,  recognized  by  the  failure  to  pass  the  stools.  The 
rectum  may  be  imperforate  at  the  anus  or  higher  up.  The 
low  cases  are  easily  operated  on  by  breaking  through  the 
septum  with  a  director.  If  the  lower  end  of  the  bowel  is  too 
high  to  reach  from  below,  or  cannot  be  found  on  dissection, 
the  only  recourse  is  an  artificial  anus  in  the  groin. 

Hypospadias :  This  abnormality  of  the  urethra  is  the  com- 
monest of  the  congenital  defects  of  this  region.  The  urethra, 
instead  of  being  continued  forward  to  the  glans  penis,  opens 
anywhere  on  the  under  surface  of  the  penis,  from  the  sulcus 
just  behind  the  glans  to  the  penoscrotal  juncture.  When 
the  opening  is  far  back  in  the  perineum  the  scrotum  may  be 
divided  into  two  halves,  giving  rise  to  the  condition  known  as 
false  hermaphroditism.  The  farther  forward  the  urethra 
opens  the  less  disagreeable  to  the  patient  the  condition  be- 
comes. There  is  nothing  serious  to  be  feared  from  it,  but  in 
adult  life  it  may  be  a  cause  of  sterility. 

Treatment:  This  is  purely  surgical,  the  operation  being 
plastic,  for  the  formation  of  a  new  urethra  from  the  end  of 
the  natural  one  to  the  glans  penis. 

Epispadias:  This  is  a  much  rarer  condition  of  urethral 
abnormality,  the  urethra  here  opening  somewhere  on  the  dor- 
sum of  the  penis.     This  is  also  of  no  importance  from  the 


EXSTROPHY  OF  THE  BLADDER— CRYPTORCHIDISM.   41 

standpoint  of  the  patient's  life,  but  may  be  a  source  of  great 
inconvenience  and  also  of  sterility. 

Treatment :  A  plastic  operation  is  the  only  method  of  cure. 

EXSTROPHY  OF  THE  BLADDER. 

Description :  This  is  one  of  the  most  distressing  deformi- 
ties of  the  new-born  infant.  The  anterior  wall  of  the  bladder, 
in  larger  or  smaller  amount,  is  wanting,  due  to  incomplete 
closure  of  the  abdominal  plates.  The  ureteral  openings  are 
usually  in  plain  sight,  and  the  urine  drips  away  continuously, 
wetting  the  clothing,  excoriating  the  skin,  and  producing  the 
disagreeable  odor  of  fermenting  urine.  The  patient  is  ob- 
jectionable both  to  himself  and  to  all  around  him.  This 
abnormality,  which  is  really  only  an  exaggerated  condition  of 
epispadias,  is  also  harmless  as  far  as  life  is  concerned. 

Exstrophy  of  the  bladder — treatment :  Only  a  complicated 
plastic  operation  can  cure  these  unfortunates.  Operation 
should  always  be  undertaken,  and  the  results  are  at  times 
fairly  good.  There  is  no  reason  why  the  operation  should 
be  postponed  later  than  five  or  six  months  of  age. 

CRYPTORCHIDISM. 

Description :  The  testicles  should  descend,  from  their  ab- 
dominal location  of  embryonal  life,  into  the  scrotum  by  the 
end  of  the  eighth  month.  Frequently  one  or  both  testicles 
may  remain  in  the  abdomen,  or  descend  only  into  the  inguinal 
canal  by  birth.  Ordinarily,  in  the  course  of  a  few  weeks, 
without  interference,  they  will  finally  reach  the  scrotum.  If 
they  remain  in  the  abdomen,  no  harm  can  come  to  them  ;  but 
if  they  are  caught  in  the  inguinal  canal,  they  are  subject  to 
traumatism,  and  may  become  inflamed  and  be  the  source  of 
great  pain. 

Cryptorchidism — treatment:  IT  the  testicles  remain  in  the 
abdomen,  nothing  should  be  done.  Tf  they  are  in  the  ingui- 
nal canal,  they  should  be  protected  from  injury  as  far  as  pos- 
sible. By  gentle  manipulation  they  can  be  assisted  in  de- 
scending to   their   proper   place.      II'   tliev   become   inflamed; 


42  DISEASES  OF  THE  NEW-BORN  INFANT. 

they  should  be  treated  by  rest  and  cold  applications.  If  they 
will  not  descend,  and  become  the  source  of  much  pain,  it  may 
be  necessary  to  remove  one  or  both  of  them.  This  is  not 
objectionable,  as  the  individual  will  probably  be  sterile  any- 
way. Orchidopexie — i.  e.,  loosening  up  the  testicle  and  su- 
turing it  in  its  proper  place  in  the  scrotum — has  been  done. 


CHAPTEE    V. 

FEEDING  OF   INFANTS. 

WOMAN'S  MILK. 

Characteristics  :  All  observers  agree  that  a  healthy  woman's 
milk  is  the  best  food  for  a  child  during  its  first  year.  This 
being  the  case,  we  must  make  a  careful  study  of  the  proper- 
ties of  healthy  human  milk. 

Woman's  milk  is  a  secretion  from  the  mammary  gland, 
formed  by  the  metamorphosis  of  the  cells  of  the  acini.  It 
consists  of  a  large  proportion  of  water,  holding  in  solution 
and  in  suspension  four  different  kinds  of  solids — proteids,  fat, 
sugar,  and  salts.  It  is  a  thin,  sweetish  fluid,  of  alkaline  re- 
action, and  with  a  specific  gravity  varying  from  1029  to  1032. 

Chemical  composition :  The  average  proportion  of  the  dif- 
ferent components  is  as  follows  :  proteids,  1  to  2  per  cent. ; 
fat,  3  to  4  per  cent.  ;  sugar,  7  per  cent. ;  salts,  .2  per  cent.  ; 
water,  87  to  88  per  cent. 

Of  course,  considerable  variations  in  any  one  milk  occur 
from  day  to  day,  and  from  week  to  week  ;  and  the  milks 
from  different  women  are  never  precisely  alike ;  but  the  ten- 
dency to  approach  the  above  standard  is  always  marked.  In 
the  first  two  weeks  and  in  prolonged  nursing  (over  ten  or 
twelve  months)  marked  differences  from  the  above  propor- 
tions are  found ;  but  during  the  intervening  time  these 
averages  may  be  expected. 

"Woman's  milk — proteids :  These  are  the  albuminous  con- 
stituents of  milk,  the  so-called  curd.  There  are  two  main 
bodies  of  this  class,  caseinogen  and  lactalbumin.  The  casein 
is  only  half  as  much  as  the  milk-albumin;  but  the  exact 
chemical  properties  of  the  whole  protcid  class  are  as  yet  not 
very  perfectly  worked  out. 


44  FEEDING   OF  INFANTS. 

They  are  the  ingredients  furnishing  the  nitrogen  to  the 
child  for  the  growth  of  the  nitrogenous  tissues  of  the  body, 
and  until  the  child  is  on  a  mixed  diet  they  are  its  only  source 
of  nitrogen.  They  are  hence  very  necessary  for  life ;  and  if 
deprived  of  the  proper  quantity,  the  infant  will  become 
anaemic,  with  weak  and  flabby  muscles  and  loss  of  flesh  and 
strength.  If  in  excess  in  the  milk,  they  are  the  most  fre- 
quent source  of  gastro-enteric  disturbance. 

Fat :  The  fat  of  milk  is  the  familiar  cream,  existing  as  an 
emulsion  of  minute  droplets  in  the  alkaline  fluid.  If  milk 
is  examined  under  a  microscope,  the  fat-globules  should  be 
the  only  elements  visible,  and  they  are  seen  as  quite  thickly 
aggregated,  highly  refractive  granules,  of  a  fairly  uniform 
size. 

The  fat  is  of  use  mainly  as  a  source  of  heat,  and  in  storing 
up  fat  around  the  various  body-tissues.  It  is  also  needed  as 
a  special  food  for  the  nerve-tissues,  and  has  some  unknown 
connection  with  the  growth  of  the  bones.  While  fat  is  not 
so  essential  to  life  as  the  proteids,  still  deprivation  of  it  is 
followed  by  rather  definite  symptoms  of  general  malnutrition 
and  anaemia,  and  among  special  symptoms  constipation  and  a 
tendency  to  the  development  of  rachitis  are  seen. 

Woman's  milk — sugar :  This  is  the  most  stable  and  least 
troublesome  ingredient  of  the  milk.  It  is  the  carbohydrate 
element,  and  is  present  as  lactose,  or  milk-sugar,  in  solution 
in  the  water. 

An  excess  of  sugar  does  not  often  cause  digestive  derange- 
ment, but  does  lead  to  a  rapid  increase  in  the  weight  and  fat 
of  the  infant ;  such  children  are  not  strong  and  resistant, 
however,  and  rapidly  fall  victims  to  acute  disease.  Sugar's 
function  is  mainly  to  produce  the  animal  heat  of  the  body, 
and  to  assist  in  the  storing  up  of  fat  around  the  tissues. 

Salts:  The  salts,  or  "  ash,"  are  the  mineral  ingredients  of 
the  milk,  consisting  mainly  of  calcium  phosphate,  potassium 
carbonate,  and  sodium  chloride.  They  are  the  great  source 
of  nutriment  for  bone,  and  supply  also  the  mineral  ingre- 
dients demanded  by  the  other  body-tissues. 

Woman's  milk — water :  This  is  necessary  in  large  amounts 
in  the  food  to  hold  the  solids  in  solution,  and  so  make  easy 


WOMAN'S  MILK.  45 

their  digestion,  and  to  supply  the  water  needed  by  all  the 
tissues  of  the  body. 

Colostrum :  During  the  first  three  or  four  days  after  the 
baby's  birth  the  breasts  secrete  the  so-called  colostrum,  which 
differs  decidedly  from  the  true  milk.  It  is  thicker  and  yel- 
lower, has  a  much  higher  specific  gravity,  and  is  very  rich  in 
proteids  and  salts.  The  fat  and  sugar  are  less  in  quantity  than 
in  true  milk,  while  there  is  present  a  considerable  number 
of  large  irregular  granular  bodies,  known  as  colostrum-cor- 
puscles. These  are  probably  cells  from  the  acini  of  the 
gland  in  which  metamorphosis  is  incomplete. 

It  is  secreted  in  comparatively  small  amounts,  and  its 
function  seems  to  be  as  a  temporary  food,  and  as  nature's 
laxative  to  remove  the  meconium. 

Woman's  milk — quantity  daily:  After  the  colostrum-period 
is  finished  the  two  breasts  secrete  daily  somewhat  the  follow- 
ing average  quantities  of  milk.  These  amounts  are  rather 
difficult  to  fix  exactly,  and  are  estimated  from  a  large  number 
of  experiments  in  pumping  the  breasts  and  measuring  the 
results ;  in  finding  the  quantity  taken  by  a  baby  by  weighing 
him  carefully  both  before  and  after  nursing  ;  and  in  esti- 
mating the  capacity  of  infants'  stomachs  at  different  periods 
of  life. 

Daily  quantity  of  milk  secreted :  During  second  week,  13  to 
18  ounces  ;  during  third  week,  14  to  24  ounces  ;  during  fourth 
week,  16  to  26  ounces;  during  second  and  third  months,  20 
to  34  ounces  ;  during  fourth  and  fifth  months,  24  to  38  ounces  ; 
during  sixth,  seventh,  and  eighth  months,  30  to  40  ounces. 

Average  quantity  at  each  nursing:  During  first  week,  f  to 
1\  ounces;  during  second  week,  1  to  3  ounces;  during  third 
week,  1 1-  to  4  ounces  ;  during  fourth  week,  1\  to  4-^  ounces  ; 
during  second  month,  2  to  5  ounces;  during  third  month,  1\ 
to  5^  ounces;  during  fourth  month,  3  to  6  ounces;  during 
fifth  month,  3^-  to  6^  ounces;  during  sixth  month,  4  to  7 
ounces. 

Of  course,  the  above  daily  amounts  and  the  quantities  at 
each  nursing  vary  markedly,  depending  on  the  amount  of  real 
brca-t-ti  —  iM',  the  general  condition  of  the  mother,  and  the  size 
and  strength  of  the  baby. 


46  FEEDING    OF  INFANTS. 

Rules  for  maternal  nursing :  If  the  mother  is  able  to  nurse 
her  child,  it  should  be  given  the  breast  regularly,  at  certain 
definite  intervals,  according  to  the  following  scheme  : 

It  should  be  allowed  to  nurse  about  twenty  minutes  on  each 
occasion,  being  at  once  awakened  if  it  goes  asleep  at  the  breast 
before  finishing  its  meal,  and  it  should  nurse  from  the  two 
breasts  alternately. 

Before  and  after  nursing  the  nipple  should  be  washed  with 
boric  acid  solution,  and  after  nursing  the  baby's  mouth  should 
be  washed  out  with  the  same. 

As  soon  as  the  meal  time  is  finished  the  baby  should  be  put 
back  into  its  own  bed,  and  left  to  go  asleep  without  rocking 
or  other  aid.  If  it  is  not  awake  by  the  time  for  its  next  meal, 
it  should  be  awakened  and  fed. 

By  beginning  from  the  first,  and  following  the  rules  abso- 
lutely, the  baby  is  quickly  trained  to  accustom  itself  to  this 
proper  way  of  feeding,  and  the  parents  are  relieved  of  the 
greatest  trials  connected  with  the  care  of  their  child.  These 
regular  nursing-habits  are  rapidly  learned,  and  are  productive 
of  many  good  results — good  digestion,  good  assimilation,  lack 
of  colic,  lack  of  crying,  prevention  of  gastro-enteric  disease, 
regularity  in  sleeping,  and  insure  regular  resting-hours  for  the 
mother.  It  is  surprising  to  discover  what  a  machine  a  baby 
can  be  made  into  :  he  will  learn  to  awake  almost  by  the  clock, 
to  go  asleep  at  once  after  feeding,  or  to  lie  awake  quiet  and 
contented.  It  is  far  more  difficult  to  introduce  these  reforms 
in  the  life  of  a  baby  who  has  been  taught  bad  habits  of  feed- 
ing, than  it  is  to  teach  them  to  a  new  baby  from  the  first. 

Feeding  scheme  :  For  two  months,  every  two  hours,  omitting 
two  feedings  at  night;  e.  g.,  7,  9,  11  A.  M. ;  1,  3,  5,  7,  9,  11 
P.  m.  ;  3,  7  A.  M.     Total,  ten. 

For  the  third  and  the  fourth  month,  every  two  and  one-half 
hours,  omitting  two  feedings  at  night;  e.  g.,  7,  9.30,  12 
A.  m.  ;  2.30,  5/7.30,  10  P.  M. ;  2.30,  7  A.  M.     Total,  eight, 

After  the  fourth  month,  every  three  hours,  omitting  all 
night-feeding;  e.  g.,  7,  10  A.  M. ;  1,  4,  7,  10  P.  M.  ;  7  A.  M. 
Total,  six. 

These    latter   intervals  are  adhered    to  till    ten  to  twelve 


WOMAN'S  MILK.  47 

months,  by  which  time  some  solid  food  is  allowed  in  addition 
to  the  breast-milk,  and  taking  the  place  of  one  or  more  of 
these  feedings. 

A  woman's  milk  as  the  food,  and  the  above  rules  in  taking 
it,  are  the  ideal  or  standard  that  should  be  aimed  at  in  feeding 
every  infant.  Unfortunately,  every  mother  cannot  nurse  her 
baby ;  some  mothers  will  not  nurse  their  babies ;  every  baby 
does  not  have  a  mother  to  nurse  it ;  and  some  mothers  do  not 
furnish  a  food  that  is  suitable  for  her  particular  baby.  Hence 
many  infants  have  to  be  raised  on  artificial  food.  Under 
such  circumstances  the  problem  is  to  furnish  the  infant  the 
best  substitute  in  quality  for  woman's  milk,  and  to  feed  this 
substitute  in  accordance  with  the  same  rules.  The  nearer  we 
can  copy  maternal  feeding  in  quality  of  food,  in  quantity 
given,  and  in  regularity  of  feeding,  the  larger  proportion  of 
artificially  fed  infants  will  be  kept  from  gastro-intestinal  and 
nutritional  disorders. 

Contraindications  for  maternal  nursing :  There  are  a  few 
justifiable  reasons  why  a  woman  should  not  nurse  her  own 
child,  even  when  she  has  sufficient  milk.  Among  these  are 
excessive  nervousness,  chorea,  epilepsy,  tuberculosis,  puerperal 
hemorrhage  (excessive),  nephritis,  eclampsia,  or  septicaemia; 
or  where  after  careful  observation  in  previous  lactations  it  has 
been  proved  that  her  milk  is  distinctly  prejudicial  to  her 
child. 

Cracking  of  the  nipples  or  inflammation  of  the  breast  may 
be  so  severe  and  painful  that  nursing  is  impossible  ;  but  there 
are  many  devices  for  remedying  these  evils,  and  often  nursing 
can  be  begun  again  after  a  temporary  cessation. 

Such  devices  are  the  nipple-shield  and  breast-pump,  and 
therapeutical  care  of  the  nipples  and  breasts  as  laid  down  in 
(lie  text-books  on  obstetrics.  In  these  two  conditions,  in  the 
absence  of  other  contraindications,  always  make  the  effort  to 
have  lactation  continued  if  possible. 

Menstruation  supervening  during  lactation  frequently  causes 
a  temporary  gastro-intestinal  disturbance;  but  the  cause  is 
all  over  in  a  few  days,  when  the  milk  again  becomes  a  suit- 
able food  for  the  child. 


48  FEEDING    OF  TNFANTS. 

If  'pregnancy  intervene,  it  is  wisest  to  stop  nursing,  as  the 
milk  rapidly  deteriorates,  since  the  strain  on  the  mother  of 
nourishing  herself,  the  child  at  her  breast,  and  the  embryo,  is 
prejudicial  to  all  three.  Further,  her  baby  has  by  this  time 
had  the  advantage  of  its  mother's  milk  for  some  months,  and 
weaning  is  of  less  importance  to  the  child  now  than  it  would 
have  been  earlier. 

Insufficient  food :  The  physician  is  often  asked  whether  he 
thinks  the  child  is  getting  enough  food,  and  as  a  matter  of 
fact  almost  any  ailment  is  ascribed  to  "  being  hungry."  It 
is  quite  important  to  know  the  signs  of  this  condition,  and  it 
is  always  well  to  try  thoroughly  to  rule  out  other  possible 
causes  before  deciding  that  the  symptoms  complained  of  are 
due  to  insufficient  food.  There  is  no  doubt  that  more  chil- 
dren are  over-fed  than  starved  ;  and  because  a  child  will  take 
more  food,  if  offered  it,  is  no  reason  why  he  needs  that  food 
for  his  nutrition. 

The  main  signs  to  be  relied  on  of  insufficient  feeding  are  : 
lack  of  the  regular  weekly  gain  in  weight,  and  very  soft, 
flabby  breasts,  from  which  only  a  very  little  milk  can  be 
gotten  at  the  nursing-time.  Less  positive,  but  confirmatory 
evidence  is  obtained  by  the  baby  napping  only  a  short  time 
after  feeding,  instead  of  sleeping  quietly  until  his  next  nursing- 
interval  ;  fretfulness  and  crying  when  awake,  it  being  certain 
that  other  causes  are  excluded  ;  irregularity  in  the  bowels, 
diarrhea  and  constipation  alternating ;  and  either  an  exces- 
sively long  or  a  very  short  time  being  taken  by  the  child  in 
emptying  the  breast. 

If  an  insufficient  amount  of  food  is  supplied  for  any  pro- 
longed time,  marked  evidences  of  malnutrition,  as  wasted 
muscles,  flabby  skin,  sunken  fontanelle,  anaemia,  and  delayed 
dentition,  are  present.  Lack  of  a  proper  quantity  of  any  of 
the  ingredients  of  the  milk  for  a  considerable  time  is  followed 
by  special  symptoms,  as  described  under  their  special  chemi- 
cal components. 

If  by  the  presence  of  the  above  signs  we  are  suspicious  of 
the  milk  as  being  the  source  of  trouble,  we  must  examine 
into   both  its  quantity  and   its   quality  before    making  any 


WOMAN'S  MILK.  49 

change,  so  as  to  discover  the  exact  cause  of  the  infant's  symp- 
toms. 

Methods  of  clinical  analysis  of  mother's  milk  :  In  investi- 
gating the  causes  of  insufficient  feeding,  and  in  watching  the 
results  of  efforts  made  to  change  the  different  milk-con- 
stituents, soon  to  be  described,  frequent  chemical  analyses 
of  the  milk  are  necessary.  Only  a  skilled  chemist  can  make 
an  accurate  analysis  of  milk,  and  frequently  we  will  have  to 
go  to  one ;  but  Holt  has  produced  a  very  simple  and  useful 
method  and  apparatus  for  ordinary  clinical  work,  which,  he 
claims,  gives  as  satisfactory  results  for  milk,  as  the  usual 
urinary  analysis  does  in  connection  with  urine. 

Holt's  test  for  clinical  examination  of  milk :  This  consists  of 
a  graduated  tube  holding  10  c.c,  a  small  specific  gravity 
float,  and  a  cylinder. 

A  little  more  than  10  c.c.  of  milk  is  required.  First  take 
the  specific  gravity  of  this  in  the  cylinder ;  then  pour  the 
milk  into  the  tube  up  to  the  10  c.c.  mark  exactly,  and  let  it 
stand  about  twenty-four  hours  at  a  nearly  uniform  tempera- 
ture of  70°  F.  ;  at  the  end  of  this  time  read  off  the  percent- 
age of  cream  on  the  graduated  tube.  The  fat  is  three-fifths 
of  this  amount. 

Now  having  the  specific  gravity  and  the  fat,  and  knowing 
that  the  sugar  is  very  constant,  we  can  reach  a  fairly  good 
estimation  of  the  percentage  of  proteids  by  remembering  that 
the  average  specific  gravity  is  1031  and  the  average  fat-per- 
centage is  3.50,  and  that  fat  decreases  the  specific  gravity  and 
proteids  increase  it.  Thus,  if  the  fat  is  high  and  the  specific 
gravity  high,  the  proteids  are  very  high  ;  if  the  fat  is  high 
and  the  specific  gravity  normal,  the  proteids  are  high  ;  if  the 
fat  is  low  and  the  specific  gravity  high,  the  proteids  are  nor- 
mal ;  if  the  fat  is  low  and  the  specific  gravity  normal,  the 
proteids  are  low;  while  if  the  fat  is  low  and  the  specific 
gravity  is  low,  the  proteids  are  very  low.  "While  not  giving 
the  exact  proportion  of  proteids  in  figures,  this  does  give  a 
general  idea  of  the  amounts  of  the  milk-constituents. 

Diet   for  nursing   women:   This   should    he   essentially   the 
same   as   for  her  in   health.      It  should   be  nutritious,  easily 
4—1).  C. 


50  FEEDING    OF  INFANTS. 

digestible,  probably  a  little  larger  in  quantity  than  under 
normal  circumstances,  and  consist  of  a  good  variety  of  the 
different  forms  of  food-stuffs.  Milk  is  the  best  staple  article, 
being  taken  in  large  quantities,  and,  if  anything  is  to  be 
taken  between  regular  meals,  nothing  is  better.  The  use  of 
beers,  malts,  and  alcoholics  is  not  of  much  special  advantage, 
none  of  them  equalling  milk  as  a  milk-producer. 

Exercise  for  nursing  women :  Exercise  is  very  important 
and  necessary  for  a  woman  who  wishes  to  nurse  her  infant. 
It  is  one  of  the  best  regulators  of  the  quality  of  the  milk, 
and  is  indirectly  of  value  in  lactation,  by  its  well-known 
power  of  keeping  the  various  functions  in  good  condition. 

Drugs  for  nursing  women  :  Drugs  are  eliminated  through  the 
milk  much  less  constantly  than  is  generally  supposed.  Still 
at  times  the  milk  does  contain  them  when  taken  by  the 
mother,  a  fact  which  must  always  be  kept  in  mind  when  pre- 
scribing for  a  nursing  woman,  and  advantage  of  which  can  be 
taken  at  times  therapeutically,  especially  in  dealing  w7ith 
syphilis.  This  method,  though,  of  treating  a  nursling  through 
its  mother's  milk  is  very  inexact,  and  cannot  be  relied  on. 

The  list  of  drugs  that  have  been  found  in  milk  is  large  ; 
some  of  the  more  important  ones  are  :  the  purgative  princi- 
ples of  rhubarb,  senna,  and  castor-oil ;  the  metals,  as  anti- 
mony, arsenic,  iodine,  lead,  iron,  and  mercury ;  volatile  oils, 
as  copaiba,  garlic,  or  turpentine ;  the  iodides  and  bromides, 
and  opium. 

Methods  of  changing  the  ingredients  in  woman's  milk :  If 
after  chemical  analysis  we  find  any  marked  changes  either  in 
the  quantity  or  the  quality  of  woman's  milk,  by  adopting 
certain  procedures  in  the  way  of  diet  and  exercise  we  can 
often  correct  these  abnormalities  and  bring  about  the  produc- 
tion of  a  milk  more  nearly  approaching  the  normal  standard, 
and  one  that  will  consequently  be  more  suitable  for  the  child's 
digestion  and  nutrition. 

Rotch  gives  a  condensed  table  for  these  changes  as  follows  : 

To  increase  the  total  quantity:  Increase  the  liquids  in  the 

mother's  diet,  especially  milk  (malt  extracts  may  be  helpful), 


WOMAN'S  MILK.  51 

and  encourage  her  to  believe  that  she  will  be  able  to  nurse 
her  infant. 

To  decrease  the  total  quantity :  Decrease  the  liquids  in  the 
mother's  diet. 

To  increase  the  total  solids:  Shorten  the  nursing-intervals, 
decrease  the  exercise,  decrease  the  proportion  of  liquids,  and 
increase  the  proportion  of  solids  in  the  mother's  diet. 

To  decrease  the  total  solids:  Prolong  the  nursing-intervals, 
increase  the  exercise,  and  increase  the  proportion  of  liquids 
in  the  mother's  diet. 

To  increase  the  fat:  Increase  the  proportion  of  meat  in  the 
diet. 

To  decrease  the  fat:  Decrease  the  proportion  of  meat  in  the 
diet. 

To  increase  the  proteids:  Decrease  the  exercise. 

To  decrease  the  proteids:  Increase  the  exercise  up  to  the 
limit  of  fatigue  for  the  individual. 

It  is  wise  in  all  cases  of  disturbed  lactation,  whether  in 
maternal  or  wet-nursing,  to  make  efforts  in  accordance  with 
these  rules  to  produce  a  milk  that  is  suitable  for  an  infant 
who  is  not  thriving,  before  changing  to  any  other  method  of 
feeding:. 

Wet-nursing :  Theoretically  the  milk  of  another  woman  is 
the  best  substitute  for  mother's  milk,  and  there  are  infants 
who  will  thrive  only  on  woman's  milk.  The  advantages  of 
wet-nursing  are  the  substitution  of  the  exact  ingredients  of 
the  milk,  without  any  previous  preparation,  in  a  sterile  con- 
dition, and  the  feeding  of  this  food  in  Nature's  way. 

In  practice,  wet-nursing  is  far  from  satisfactory,  and  its 
difficulties  are  many.  The  disadvantages  are  trouble  and 
expense  in  getting  a  proper  nurse  of  good  character,  good 
habits,  and  ability  to  nurse  her  foster-child. 

( load  moral  qualities  are  necessary  for  many  reasons.  Her 
relations  with  the  child  and  the  family  will  bo  so  intimate 
that  of  necessity  the  growing  child  will  be  influenced  by  its 
association  with  her,  and  the  peace  of  mind  of  the  family  will 
!)«•  dependent  on  her.  If  of  bad  temper,  or  free  from  a  sense 
of  responsibility,  she   soon    learns   that  her  services  may  be 


52  FEEDING    OF  INFANTS. 

indispensable,  and  then  she  will  take  advantage  of  this  fact 
on  the  least  provocation.  She  may  leave  suddenly  at  a  time 
when  such  a  change  to  the  child  is  distinctly  dangerous.  If 
intemperate,  or  dissolute,  she  may  get  intoxicated  at  any  time, 
or  may  contract  some  venereal  disease,  after  which  occurrences 
she  is  distinctly  dangerous  to  the  child. 

In  this  country  the  average  wet-nurse  is  the  mother  of  an 
illegitimate  child,  or  a  married  woman  in  extreme  poverty. 
Neither  can  be  thoroughly  depended  on,  but  any  other  kind  is 
very  difficult  to  obtain.  No  woman  with  an  illegitimate  child 
other  than  the  first  should  be  taken,  as  in  other  cases  the 
moral  qualities  will  be  undoubtedly  such  as  to  make  the 
woman  positively  unfit  to  nurse. 

Physical  qualities:  A  good  wet-nurse  should  be  between 
twenty  and  thirty-five  years  of  age,  of  healthy  appearance, 
not  anaemic,  and  absolutely  free  from  present  or  past  taint  of 
tuberculosis  or  syphilis.  The  physician  should  examine  care- 
fully her  mouth,  teeth,  and  throat,  her  subcutaneous  glands 
and  skin,  her  legs,  the  tibia?  especially,  and  the  genitals,  if 
suspicious. 

The  breasts  should  be  firm  and  conical,  and  present  evi- 
dences of  abundant  gland-tissue  rather  than  be  large  sized ; 
while  the  nipples  should  be  large,  protruding,  and  free  from 
fissures  or  erosions. 

Before  engaging  her  it  is  well  to  have  a  chemical  analysis 
of  her  milk  made. 

Age  of  milk :  The  milk  should  be  somewhat  of  the  age  of 
her  foster-child ;  although  a  difference  of  four  months  is  of 
little  moment,  except  if  she  is  to  nurse  a  very  young  infant, 
when  her  milk  should  not  be  more  than  two  months  old. 
The  very  best  evidence  as  to  the  quality  of  her  milk  can  be 
obtained  by  observing  its  effect  on  the  digestion  and  nutrition 
of  her  own  child. 

Change  of  nurse :  Even  after  the  most  critical  examination 
of  the  nurse  and  her  own  child  her  milk  may  not  be  a  satis- 
factory food  for  her  foster-child,  and  we  may  have  to  change, 
and  try  again  until  a  nurse  is  found  whose  milk  is  fitted  to 
the  foster-child's  stomach.     Before  doing  this  though,  always 


MIXED  FEEDING.  53 

apply  the   rules  for  changing  the  ingredients  in  a  woman's 
milk. 

Causes  affecting  quality  of  milk  :  Often  in  obtaining  a  wet- 
nurse  the  marked  change  in  her  diet,  and  the  diminution  in 
the  quantity  of  exercise  she  has.  been  accustomed  to  take,  are 
responsible  for  the  milk  being  unfit.  In  our  country  a  wet- 
nurse  usually  puts  her  own  baby,  if  she  has  not  lost  it,  in  an 
institution,  or  boards  it  out  with  some  woman  who  makes  a  busi- 
ness of  such  work,  as  the  wet-nurse  is  expected  to  give  all  her 
time  and  all  her  milk  to  the  foster-child.  Her  own  child  fre- 
quently gets  sick,  and  often  dies  as  the  result  of  this  marked 
change  in  its  way  of  living.  The  worry  over  this  is  another 
great  cause  of  change  in  her  own  milk,  making  it  unfit  for  the 
foster-child.  If  physicians  and  well-to-do  people,  in  hiring  a 
wet-nurse,  would  take  pains  to  remedy  this  misfortune,  they 
would  prevent  one  of  the  causes  which  interfere  with  the 
happiness  of  the  wet-nurse  and  consequently  with  the  quality 
of  her  milk.  In  wet-nursing,  precisely  the  same  rules  as  to 
frequency  and  regularity  of  feeding  should  be  followed  as  in 
maternal  nursing. 

MIXED  FEEDING. 

By  this  is  meant  a  combination  of  breast  and  artificial  feed- 
ing. It  is  frequently  helpful  to  accustom  a  baby  fairly  early 
to  take  water,  or  some  little  food  once  a  day  from  a  bottle. 
This  prepares  him  for  its  use  in  case  some  sudden  emergency 
should  arise  when  the  ordinary  breast-milk  could  not  be 
given. 

In  the  later  stages  of  lactation  it  often  happens  that  the 
mother  is  unable  to  furnish  enough  milk  for  a  large,  vigorous 
baby,  and  then  one  or  more  bottles  a  day  can  be  well  used  to 
supplement  the  maternal  supply. 

When  a  baby  is  wet-nursed  it  is  still  wiser  to  use  a  bottle 
a  day,  as  frequently  a  given  wet-nurse  must  be  dispensed 
with  either  voluntarily  or  involuntarily,  in  which  case  the 
infant  is  not  left  entirely  in  the  lurch. 

In  any  case  the  proposition  that  partial  breast  and  partial 
artificial  is  always  to  be  preferred  to  complete  artificial  feed- 
ing, is  to  be  remembered. 


54  FEEDING   OF  INFANTS. 

In  giving  a  child  artificial  food  when  he  is  on  breast-milk 
mainly,  it  is  always  well  to  have  a  chemical  analysis  made 
of  the  breast-milk  on  which  he  is  thriving,  and  to  compose 
the  artificial  food  in  conformity  with  this.  If  any  one  ele- 
ment in  the  breast-milk  is  lacking,  this  can  often  be  supplied, 
with  advantage,  by  an  increased  quantity  of  this  element  in 
the  artificial  food. 

WEANING. 

Indications :  Nature  often  indicates  the  time  that  this 
change  in  feeding  should  be  brought  about  by  either  an  evi- 
dent insufficiency  in  the  mother's  milk  or  by  the  continued 
absence  of  the  regular  weekly  gain  in  the  child's  weight. 
The  regular  weighings  show  one  of  their  marked  uses  here. 
These  two  points,  combined  with  the  presence  of  six  or  eight 
teeth,  and  with  the  season  of  the  year,  are  of  more  impor- 
tance in  deciding  on  the  time  for  weaning  than  the  mere  age 
of  the  infant.  So  long  as  the  mother's  milk  holds  out  well, 
and  she  herself  is  not  suffering  from  the  drain,  and  so  long 
as  the  child  is  gaining  in  weight  and  is  healthy,  be  in  no 
hurry  to  wean. 

The  presence  of  teeth  shows  that  the  starch-digesting  func- 
tions are  ready,  makes  sucking  somewhat  painful  for  the 
mother,  and  is  an  indication  that  the  time  for  additional  food 
to  the  breast-milk  is  arriving.  Other  things  being  equal, 
choose  any  time  of  the  year  than  hot  weather  for  weaning  a 
baby. 

Methods :  Weaning  had  best  be  done  gradually  by  the 
addition  of  more  and  more  artificial  feedings,  and  the  lessen- 
ing of  the  breast-feedings,  until  the  latter  are  replaced.  Here 
comes  in  the  value  of  the  early  training  to  mixed  feeding 
advised  in  a  preceding  paragraph.  Weaning  in  such  a  case 
is  easy,  and  usually  without  incident.  The  average  time  for 
weaning  is,  in  this  country,  in  the  neighborhood  of  the  ninth 
month. 

COWS'  MILK. 

Practically  the  only  substitute  for  permanent  artificial  feed- 
ing of  infants  is  cows'  milk  so  modified  as  to  make  it  agree 


COWS'  MILK.  55 

chemically  as  nearly  as  possible  with  human  milk.  The 
proximate  principles  in  cows'  milk  are  the  same  as  those  in 
woman's  milk,  but  in  different  proportions.  There  is  un- 
doubtedly some  indefinable  chemical  or  physical  difference 
in  these  proximate  principles,  in  quality  also;  but  for  prac- 
tical purposes  we  have  to  ignore  this,  and  use  them  as  being 
the  same  until  further  investigation  discovers  what  these 
differences  are,  and  teaches  us  how  to  modify  their  quality 
as  well  as  their  quantity. 

Cows'  milk — chemical  composition  :  Fresh  cows'  milk  is  of 
neutral  or  slightly  acid  reaction,  the  specific  gravity  varies 
from  1028  to  1033,  and  it  consists  of  water  holding  in  solu- 
tion and  in  suspension  four  kinds  of  solids — proteids,  fat, 
sugar,  and  salts.  The  average  proportions  of  these  are  as 
follows  :  proteids,  4  per  cent.  ;  fat,  4  per  cent. ;  sugar,  4.5 
per  cent. ;  salts,  .7  per  cent.  ;  water,  87  per  cent. 

Comparison  of  cows'  and  woman's  milk:  Comparing  these 
proportions  with  those  in  the  table  for  woman's  milk,  we  find 
that  there  is  a  marked  excess  of  proteids  and  salts  and  a 
deficiency  in  sugar,  while  the  fat  and  the  water  are  com- 
paratively alike. 

Cows'  milk — proteids :  The  proteids  differ  from  those  in 
human  milk  not  only  in  quantity,  but  in  the  relative  propor- 
tions of  caseinogen  and  lactalbumin,  the  caseinogen  here  being 
four  times  the  lactalbumin,  instead  of  one-half  of  it  as  in 
human  milk.  This  explains  the  large  firm  clots  formed  by 
cows'  milk  when  coagulated  by  the  stomach  acids,  as  com- 
pared with  the  small  curds  from  woman's  milk,  and  hence 
the  difficulty  experienced  by  infants  in  digesting  the  proteids 
of  cows'  milk.  In  fact,  the  indigestibility  of  cows'  milk  for 
the  average  infant  is  entirely  due  to  the  proteids. 

Cows'  milk — fat :  The  fat  is  similar  in  quality  as  well  as 
quantity,  and  presents  nothing  of  interest  from  a  digestive 
standpoint.  The  fat  of  milk  is  represented  by  the  well- 
known  cream,  which  by  its  lighter  specific  gravity  rises  to  the 
top  when  milk  is  left  to  stand. 

Sugar:  The  sugar  of  milk,  or  lactose,  is  the  same  in  both 
kinds  of  milk;  but  being  in  smaller  quantity  in  cows'  milk 
makes  tin-  far  less  sweet   to  the  taste,  and,  what  is  of  more 


56  FEEDING   OF  INFANTS. 

importance,  of  far  less  nutritive  value  from  the  carbohydrate 
standpoint.  This  lack  of  sweetness  sometimes  explains  the 
reason  why  babies  object  to  cows'  milk  at  first. 

Salts  :  These  are  three  and  a  half  times  as  abundant  in 
cows'  milk,  with   a  marked  excess  of  calcium  phosphate. 

Cows'  milk — germ  life :  Not  only  should  the  difference  in 
reaction  be  noted,  but  most  important  is  the  fact  that  human 
milk  as  sucked  from  the  breast  is  sterile,  while  cows'  milk,  as 
a  commercial  article,  always  contains  bacteria  in  varying 
numbers. 

Sources :  It  makes  little  difference  what  breeds  of  cows 
the  milk  comes  from,  but  there  are  a  few  points  worthy  of 
mention  in  this  connection.  Contrary  to  the  general  idea, 
mixed  milk  from  a  herd  is  preferable  to  that  from  one  cow, 
as  one  cow's  milk  is  far  more  apt  to  vary  in  its  proportions 
from  time  to  time  than  the  mixed  product  of  a  herd. 
Further,  if  this  one  cow  should  be  diseased,  the  infant  is 
far  more  exposed  to  infection  than  when  the  milk  of  one 
diseased  cow  is  diluted  by  the  milk  from  a  healthy  herd. 

Milk  from  the  Jerseys  and  Alderneys  is  much  richer  in  fat 
than  that  of  any  other  breed,  but  unfortunately  these 
varieties  are  more  prone  to  tuberculosis  than  the  commoner 
breeds.  Tuberculosis  is  a  very  common  disease  in  cows,  and 
should  be  always  guarded  against  in  a  milk-supply.  All 
herds  used  for  dairy  purposes  should  be  tested  at  frequent 
intervals  for  tuberculosis,  and  the  suspicious  animals  destroyed, 
and  no  new  cows  should  be  added  to  the  herd  until  they  are 
proved  free  from  tuberculosis. 

Cows'  milk — its  care :  The  cows  should  be  milked  with 
aseptic  precautions,  the  udder  and  teats  being  washed  before 
milking,  the  milker's  hands  being  thoroughly  cleansed,  and 
the  receptacles  for  the  milk  being  sterile.  In  this  way  a 
milk  with  as  few  germs  as  possible  is  obtained,  and  the 
chances  of  its  undergoing  change  by  the  development  of 
toxins  are  reduced  to  a  minimum.  The  milk  should  be  used 
as  fresh  as  possible ;  every  hour  it  is  kept  after  milking  before 
use  adding  to  the  possibility  of  its  developing  some  change 
making  it  less  fit  for  food.  Milk  which  is  cooled  directly 
after  milking  keeps  the  best  of  any  on  the  market. 


COWS'  MILK.  57 

Cows'  milk — sterilization :  By  these  methods  a  milk  is  ob- 
tained as  nearly  sterile  as  possible,  or  what  might  be  called 
"  aseptic  milk."  But  with  the  greatest  precautions — and  these 
are  hard  to  effect  in  the  ordinary  dairy — all  milk  contains 
more  or  less  bacteria.  As  a  consequence  the  process  of  steril- 
ization is  much  used,  especially  during  hot  weather,  to  destroy 
the  bacteria  in  milk. 

By  this  process  is  meant  the  prolonged  heating  of  the  milk 
at  212°  F.,  by  the  action  of  steam  or  boiling  water.  It  is 
usually  subjected  to  the  action  of  heat  at  this  temperature  for 
twenty  minutes  or  more.  This  accomplishes  the  destruction 
of  the  ordinary  germs  upon  which  the  diarrhoeal  diseases  de- 
pend, as  well  as  the  tubercle  bacillus,  the  germs  of  diphtheria, 
typhoid,  and  others. 

Such  milk  keeps  well,  and  does  not  cause  digestive  trou- 
bles ;  but  certain  other  and  undesirable  changes  take  place  at 
the  same  time  :  the  taste  of  the  milk  is  changed  to  that  of 
boiled  milk,  which  is  disagreeable  to  some ;  the  sugar  is  par- 
tially burned,  giving  the  milk  a  brownish  appearance ;  and 
the  casein  is  rendered  more  difficult  of  digestion.  Children 
fed  on  this  for  any  length  of  time  are  likely  to  be  constipated, 
and  there  is  much  authority  for  the  statement  that  prolonged 
use  of  sterilized  milk  causes  rickets  and  at  times  scurvy,  from 
the  destruction  by  the  heat  of  "  the  vital  principle  "  of  the 
milk.     This  latter  point,  however,  is  still  an  open  question. 

Sterilization — methods :  Milk  may  be  sterilized  by  putting 
the  receptacle  containing  the  milk  in  a  vessel  of  water  and 
boiling  this  water  for  the  required  time.  The  Arnold  steam- 
sterilizer  is  a  practical  apparatus  for  accomplishing  this  by  the 
action  of  steam  circulating  in  a  confined  chamber  around  the 
vessels  containing  the  milk.  Milk  is  best  sterilized  in  the 
bottles  it  is  to  be  fed  from. 

Cows'  milk — pasteurization  :  Since  the  profession  has  appre- 
ciated that  the  sterilization  of  milk  has  its  drawbacks,  efforts 
have  been  made  to  find  a  method  of  destroying  the  bacteria 
in  milk  without  producing  these  objectionable  changes  in  the 
milk-constituents.  The  method  now  much  used  with  this  end 
in  view  is  called  pasteurizing,  and  is  based  on  the  idea  of  using 
the  least  amount  of  heat  that  will  destroy  the  ordinary  bac- 


58  FEEDING   OF  INFANTS. 

teria  that  are  injurious  in  milk.  This  amount  of  heat  has 
been  found  to  be  167°  F.,  and  milk  brought  to  and  retained 
at  this  temperature  for  twenty  minutes  is  found  to  be  free 
from  bacterial  growth,  and  to  show  far  less  of  the  objection- 
able changes  than  when  subjected  to  a  temperature  of  212° 
F.  for  a  prolonged  period.  Such  milk  will  not  keep  so  long 
as  sterilized  milk,  and  cases  have  been  reported  in  which  pas- 
teurization seemed  insufficient  to  prevent  the  growth  of  the 
ordinary  bacteria  of  diarrhoea.  Neither  sterilization  nor  pas- 
teurization is  perfect. 

Pasteurization — methods :  Pasteurization  is  best  accom- 
plished by  means  of  Freeman's  pasteurizer,  an  apparatus  con- 
taining enough  boiling  water  to  bring  a  certain  amount  of 
milk  in  bottles  immersed  in  it  to  1 67°  F.  by  its  latent  heat,  and 
to  keep  the  milk  at  this  temperature  for  twenty  minutes. 
Without  some  such  apparatus  it  is  difficult  to  keep  water  at  a 
uniform  temperature  of  167°  F.  with  a  continuous  heat-supply. 

The  important  point  to  be  remembered  in  pasteurizing  is 
quickly  to  cool  the  milk  after  it  has  been  kept  at  the  requisite 
temperature  of  167°  F.  for  twenty  minutes,  by  placing  it  on 
ice  and  keeping  it  there. 

Either  pasteurization  or  sterilization  is  necessary  during  the 
hot  weather  of  summer ;  but  may  frequently  be  dispensed 
with  in  cool  weather.  Remember  that  they  are  used  as  pre- 
ventives of  digestive  disorders,  and  not  to  cure  them  when 
once  started. 

ARTIFICIAL  FEEDING. 

We  have  seen  that  cows'  milk  contains  the  same  proximate 
principles  as  woman's  milk,  but  in  different  proportions.  The 
problem  of  preparing  cows'  milk  for  use  as  an  infant-food 
consists  in  so  changing  these  proportions  by  addition  and  sub- 
traction as  to  make  a  milk  in  which  the  proximate  principles 
are  virtually  the  same  in  quantity  as  those  in  woman's  milk. 
Knowing  the  average  percentage  of  the  constituents  of  human 
milk,  and  the  exact  analysis  of  the  cows'  milk  we  are  to  mod- 
ify, it  becomes  a  matter  of  comparative  ease  to  produce  an 
infant-food  such  as  is  proper  for  the  average  child.  In  indi- 
vidual cases  circumstances  may  be  such  as  to  require  some  far 


ARTIFICIAL  FEEDING.  59 

different  proportion  of  the  proximate  principles  than  the 
average  child  needs.  These  changes  in  individual  cases, 
although  a  little  more  difficult  in  their  technique,  can  still  be 
produced  by  a  little  intelligent  thought  and  care. 

Artificial  feeding — preparation  of  cows'  milk :  We  have 
cows'  milk  giving  by  analysis  :  proteids,  4  per  cent. ;  fat,  4 
per  cent. ;  and  sugar,  4.5  per  cent. ;  and  wish  to  modify 
this  to  analyze :  proteids,  1.5  per  cent. ;  fat,  4  per  cent. ; 
and  sugar,   7  per  cent. 

Proteids :  By  adding  two  parts  of  sterile  water  to  one  part 
of  such  milk  we  bring  the  proteids  to  1.33  per  cent.,  about 
the  desired  amount;  but  this  reduces  the  fat  also  to  1.33  per 
cent,  and  the  sugar  to  1.5  per  cent.  Manifestly  such  a  milk 
is  markedly  deficient  in  two  of  the  main  food-constituents, 
and  although  the  child  would  probably  digest  such  a  food 
well,  nutritive  derangements  would  soon  follow. 

Sugar:  To  bring  this  diluted  milk  to  the  proper  sugar- 
percentage,  we  add  5J  per  cent,  of  milk-sugar,  the  amount 
for  any  definite .  quantity  of  milk  being  easily  computed. 
This  is  about  a  teaspoonful  of  milk-sugar  to  four  ounces  of 
milk. 

Milk-sugar  is  preferable  mainly  because  it  is  the  natural 
sugar  of  milk  ;  but  cane-sugar  may  be  used  with  impunity  if 
good  milk-sugar  is  difficult  to  obtain.  The  results  of  infant 
feeding  while  using  cane-sugar  seem  equally  as  good  as  when 
milk-sugar  is  used.  In  using  cane-sugar  a  somewhat  smaller 
quantity,  as  a  teaspoonful  to  six  ounces  of  milk,  is  necessary. 

Fat :  To  bring  the  fat  to  the  desired  amount,  cream  of  a 
known  percentage  may  be  added ;  but  this  introduces  some 
proteids  and  some  sugar  with  it.  The  best  and  simplest  way 
is  to  take  five  times  as  much  milk  as  it  is  desired  to  dilute  for 
twenty-four  hours'  feeding  of  the  baby,  and  let  this  stand 
about  six  hours  on  iee  in  a  glass  jar.  At  the  end  of  this 
time  skim  off  the  top  fifth.  This  is  top-milk,  so  called,  and 
analyzes  about  12  per  cent,  of  fat,  with  proteids  and  sugar 
each  about  I  per  cent.  If  this  top-milk  is  diluted  with  two 
parts  of  sterile  water,  we  have  the  proteids  1 .33  per  cent., 
the  fat  4  per  cent.,  and  the  sugar  1.5  per  cent.  Now  only 
the  addition  of  the  5.5  per  cent,  of  lactose  is  required. 


60  FEEDING   OF  INFANTS. 

Example :  As  an  example,  suppose  we  had  a  baby  who 
needed  thirty  ounces  of  food  a  day.  One-third  of  this,  or 
ten  ounces,  would  be  milk,  so  we  would  set  aside  five  times 
this,  or  fifty  ounces,  to  cool  on  ice  for  six  hours.  At  the  end 
of  this  time  we  would  take  off  the  top  ten  ounces  of  this 
milk,  which  would  contain  4  per  cent,  of  proteids,  12  per 
cent,  of  fat,  and  4  per  cent,  of  sugar.  To  this  we  would  add 
twenty  ounces  of  sterile  water  in  which  was  dissolved  5.5 
per  cent,  of  thirty,  or  a  little  more  than  an  ounce  and  a  half 
of  milk-sugar.  This  makes  thirty  ounces  of  milk  analyzing  : 
proteids,  1 .33  per  cent. ;  fat,  4  per  cent. ;  sugar,  7  per  cent. ; 
salts,  .23  per  cent.  The  only  change  left  is  due  to  the  cows' 
milk  being  acid  in  reaction,  which  is  overcome  by  the  addi- 
tion of  bicarbonate  of  sodium,  one  grain  to  the  ounce,  here 
adding  thirty  grains ;  or  of  lime-water,  one  to  twenty,  here 
adding  an  ounce  and  a  half.  In  alkalinizing  with  lime-water 
we  must  remember  that  the  water  further  dilutes  our  milk, 
and  must  leave  out  that  much  of  the  diluting  water. 

At  times,  instead  of  diluting  the  top-milk  with  sterile 
water,  barley-  or  oatmeal-water  is  used  as  a  diluent.  Either 
may  be  made  by  boiling  an  ounce  of  barley  or  oatmeal  in  a 
quart  of  water  to  a  pint  and  then  straining  for  use.  They 
are  somewhat  pasty,  and  are  supposed  to  assist  in  the  diges- 
tion of  the  casein  ;  and  the  oatmeal- water  to  be  of  value  in 
constipation. 

After  the  total  quantity  of  food  is  modified  to  the  right 
proportions  it  is  separated  into  the  requisite  number  of 
nursing-bottles  for  a  day's  supply,  each  bottle  holding  the 
proper  quantity.  These  are  then  stoppered  with  ordinary 
non-absorbent  cotton,  and  are  sterilized  or  pasteurized  if  re- 
quired ;  or  if  the  process  of  preparation  has  been  carried  on 
aseptically,  are  simply  set  aside  in  the  refrigerator.  When 
ready  to  use,  the  bottle  is  warmed  to  about  98°  F.,  the  tem- 
perature for  eating,  the  cotton  is  removed,  and  a  clean  nipple 
applied  over  the  neck. 

Artificial  feeding — rules  for  feeding :  The  average-sized 
child  should  be  fed  certain  definite  quantities  of  this  milk  at 
certain  definite  intervals,  a  scheme  being  constructed  using 
the  same  intervals  as  in  breast-feeding,  and  calculating  the 


ARTIFICIAL   FEEDING. 


61 


amount  at  a  feeding  by  the  average  quantity  obtained  from  a 
breast. 

Scheme  for  Artificial  Feeding  during  the  First  Year. 
(The  Feedings  begin  at  7  A.  M.) 


Age. 


1  week 

2  weeks  . 
4  weeks  . 
6  weeks    . 

2  months 

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4  months 

5  months 

6  months 

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The  bottle  should  be  finished  in  twenty  minutes;  if  not, 
take  it  away.  Do  not  warm  the  remnant  and  give  it  again 
to  the  baby. 

By  the  time  the  tenth  month  is  finished  the  average  baby 
begins  taking  some  other  form  of  food  as  a  substitute  for  one 
or  more  of  the  milk-feedings. 

In  large,  robust  children  somewhat  larger  quantities  than 
the  above  averages  are  better;  while  in  small,  delicate  chil- 
dren smaller  quantities  are  prescribed.  The  stomach  un- 
doubtedly bears  some  direct  ratio  in  size  to  the  weight  of  the 
infant,  a  point  which  should  be  remembered  in  deciding  on 
the  proper  quantity  of  milk  to  be  given  a  particular  infant  at 
a  nursing.  The  regular  weekly  weighings  are  here  of  equal 
value  as  in  breast-feeding  as  an  index  of  whether  the  baby  is 
being  properly  nourished, 


62  FEEDING    OF  INFANTS. 

Artificial  feeding — care  of  bottles  and  nipples :  The  best 
bottles  are  graduated,  for  ease  in  measuring  the  food ;  and 
have  wide  neck  and  sloping  shoulders,  for  ease  in  cleaning. 
They  should  be  kept  scrupulously  clean  of  all  evident  signs 
of  milk  or  foreign  matter,  and  before  being  filled  with  the 
milk  should  be  boiled. 

The  best  nipples  are  of  black  rubber,  and  large  enough  to 
fit  over  the  neck  of  the  bottle  and  to  be  turned  inside  out 
for  cleaning.  Those  with  a  rubber  tube  connecting  them  to 
the  bottle  and  running  into  the  milk  should  not  be  used,  as 
it  is  almost  impossible  to  keep  them  clean.  The  nipple 
should  be  cleaned  thoroughly  after  use,  and  kept  in  a  borax 
solution  when  not  in  use.  The  hole  in  the  nipple  should  be 
large  enough  to  allow  the  milk  to  drop  out,  but  not  to  run  in 
a  stream. 

Milk  laboratories :  There  have  been  established  in  very 
recent  years  in  many  of  the  large  cities  of  the  United  States 
milk  laboratories  for  the  exact  modification  of  cows'  milk  to 
fit  it  for  infant  feeding.  At  these  laboratories  the  milk  is 
ordered  by  prescription  exactly  as  drugs  are  ordered  by  pre- 
scription at  the  apothecary's.  Each  laboratory  is  a  branch 
of  the  original  Walker-Gordon  laboratory  founded  in  Boston 
under  the  supervision  of  Rotch.  Each  laboratory  has  its 
own  herd  of  cows,  which  are  fed  and  housed  with  great 
hygienic  care,  and  are  tested  for  tuberculosis  regularly  with 
tuberculin.  The  milk  is  milked  and  shipped  to  the  labora- 
tory under  aseptic  precautions.  At  the  laboratory  it  is  sepa- 
rated in  a  centrifugal  machine  and  a  16  per  cent,  cream 
obtained.  The  skimmed  milk  is  used  for  the  proteids,  and  a 
25  per  cent,  solution  of  lactose  for  the  sugar.  The  chemist 
at  the  laboratory  knows  the  quantity  of  proteids  and  sugar 
in  the  16  per  cent,  cream,  and  the  quantity  of  proteids,  fat, 
and  sugar  in  the  skimmed  milk.  With  these  and  the  definite 
solution  of  milk-sugar  he  can  form  modified  milk  of  any 
definite  strength  of  proteids,  fat,  and  sugar. 

The  physician  in  ordering  the  milk  knows  the  requirements 
of  his  particular  case,  and  on  a  prescription-blank  prepared 
for  this  purpose  writes  the  order  for  the  modified  milk  to  be 
delivered  ready  for  feeding. 


ARTIFICIAL  FEEDING.  63 

The  form  of  prescription-blank  is  as  follows  : 

1^  Proteids,       %.  Alkalinity,  %. 

Fat,  %.  No.  of  feedings, 

Sugar,  %.  Amount  at  each  feeding,       5. 

Heat  to      °  F. 

This  being  filled  out  by  the  physician,  as  required,,  is  sent 
to  the  laboratory,  and  each  day  thereafter,  until  changed  by 
the  physician,  a  basket  of  the  required  number  of  bottles  for 
twenty-four  hours  is  delivered,  each  bottle  containing  the 
exact  quantity  of  milk  of  the  proper  proportions  ready  for 
feeding.  This  should  be  kept  in  a  cool  place,  and  when  a 
bottle  is  to  be  fed  it  should  be  warmed  to  the  proper  tem- 
perature for  feeding  (98°  F.),  the  cotton  stopper  removed, 
and  the  nipple  applied. 

Milk  laboratories — their  advantages :  Food  prescribed 
through  the  medium  of  the  laboratory  has  the  advantage  of 
accuracy  of  percentage  of  constituents,  of  exact  quantity  at 
a  feeding,  of  sterility  of  the  milk,  and  of  ease  of  changing 
the  percentages  gradually  and  exactly  as  conditions  demand. 
Further,  it  is  next  to  impossible  for  the  family  to  make  any 
change  in  the  quality  or  quantity  of  this  milk  without  the 
knowledge  of  the  physician,  a  fact  of  value  in  dealing  with 
difficult  cases  of  digestion  or  nutrition. 

Artificial  feeding — home  modification  :  The  great  disadvan- 
tage of  the  milk  laboratory  is  its  expense,  thus  putting  such 
milk  out  of  reach  of  the  masses  of  the  people.  With  patients 
who  cannot  afford  this  milk,  and  in  localities  where  there  are 
no  laboratories,  home  modification  is  our  only  resource. 
Modification  at  home  can  be  done  with  some  little  trouble,  and 
although  exact  percentages  cannot,  of  course,  be  gotten,  com- 
parative  accuracy  can  be  attained  and  a  good  substitute  for 
laboratory-milk  produced.  Frequently,  in  cases  requiring 
much  care  in  feeding,  laboratory-milk  may  lie  used  tempo- 
rarily until  improvement  begins,  when  home  modification  can 
be  substituted,  thus  using  the  expensive  milk  lor  a  short  time 
only. 

Home    modification — Coit's    decimal    method:    This    is    the 


64  FEEDING    OF  INFANTS. 

simplest  and  easiest  worked  method  of  home  modification 
yet  suggested.  It  is  based  on  the  metric  system,  and  all  the 
calculations  are  made  in  decimals. 

Three  solutions  are  required  :  1.  A  decimal  (10  per  cent.) 
cream,  or  super-fatted  milk  for  introducing  the  fat ;  2.  A 
saccharated  (10  per  cent.)  skimmed  milk  for  introducing  pro- 
teids  not  carried  by  the  cream  ;  3.  A  standard  (10  per  cent.) 
sugar  solution  for  introducing  the  lactose  not  carried  by  the 
cream  or  the  skimmed  milk.  Solutions  1  and  3  only  are 
required  when  the  proteid  percentage  is  small.  As  the  child 
grows  older,  and  a  higher  proteid  percentage  is  necessary, 
solution  2  is  required  also. 

Decimal  cream  is  produced  by  allowing  a  quart  of  ordinary 
fresh  milk  from  a  mixed  herd  to  stand  on  ice  for  fifteen 
hours,  and  at  the  end  of  this  time  one-fifth  of  it  is  taken 
from  the  top.  This  averages  15  per  cent,  of  fat,  and  loses 
about  \  per  cent,  each  of  sugar  and  proteids.  If  to  this  we 
add  one-half  its  volume  of  water,  a  decimal  cream  is  obtained, 
analyzing:  10  per  cent,  of  fat,  2.33  per  cent,  of  proteids, 
and  2.66  per  cent,  of  sugar.  From  this  the  following  for- 
mulae, showing  the  amounts  of  proteids  and  lactose  coincidently 
introduced  with  any  definite  fat-percentage,  are  easily 
deduced : 

Decimal  cream  in  introducing  4  per  cent,  of  fat,  also  intro- 
duces 1  per  cent,  of  proteids  and  1  per  cent,  of  lactose. 
Decimal  cream  in  introducing  3.5  per  cent,  of  fat,  also 
introduces  .8  per  cent,  of  proteids  and  .9  per  cent,  of  lactose. 
Decimal  cream  in  introducing  3  per  cent,  of  fat,  also  intro- 
duces .7  per  cent,  of  proteids  and  .8  per  cent,  of  lactose. 
Decimal  cream  in  introducing  2.5  per  cent,  of  fat,  also 
introduces  .6  per  cent,  of  proteids  and  .7  per  cent,  of  lac- 
tose. Decimal  cream  in  introducing  2  per  cent,  of  fat,  also 
introduces  .5  per  cent,  of  proteids  and  .5  per  cent,  of 
lactose. 

Saccharated  skimmed  milk  depends  on  the  fact  that 
skimmed  milk  analyzes  4  per  cent,  of  proteids  and  5  per 
cent,  of  sugnr.  Five  per  cent,  more  of  lactose  is  added 
simply  for  convenience  of  calculation.  This  means  adding 
one  ounce  by  weight  of  lactose  to  twenty  ounces  of  skimmed 


ARTIFICIAL  FEEDING.  65 

milk.  Our  solution  then  analyzes  :  proteids  4  per  cent,  and 
lactose  10  per  cent.  If  we  wish  to  add  1  per  cent,  of  pro- 
teids, we  use  one-fourth  of  the  total  food  required  from 
solution  2  ;  if  .5  per  cent,  of  proteids,  one-eighth,  etc.,  al- 
ways remembering  that  we  introduce  coincidently  two  and 
one-half  times  as  much  sugar.  The  formulae  here  deduced 
are  also  plain : 

Amount  of  food  in  c.c.  X|  (saccharated  skimmed  milk) 
adds  proteids  .5  per  cent,  and  lactose  1.25  per  cent.  Amount 
of  food  in  c.c.  X^  (saccharated  skimmed  milk)  adds  proteids 
1  per  cent,  and  lactose  2.5  per  cent.  Amount  of  food  in 
c.c.  Xf  (saccharated  skimmed  milk)  adds  proteids  1.5  per 
cent,  and  lactose  3.75  per  cent.  Amount  of  food  in  c.c.  X-§- 
(saccharated  skimmed  milk)  adds  proteids  2  per  cent,  and 
lactose  5  per  cent. 

Standard  sugar  solution  is  prepared  by  dissolving  10  per 
cent,  of  lactose  in  sterile  water,  or  two  ounces  by  weight  in 
twenty  ounces  of  water. 

In  calculating  formulae  four  facts  only  are  necessary  :  the 
quantity  of  food  required ;  the  percentage-formulte  required  ; 
that  the  standards,  except  the  proteids,  are  10  per  cent. ;  and 
the  quantity  of  other  constituents  introduced  with  the 
standards. 

With  these  facts  in  mind,  all  that  is  necessary  further  is  to 
reduce  the  quantity  expressed  in  ounces  to  cubic  centimetres 
by  multiplying  by  thirty,  and  to  multiply  this  product  by 
one- tenth  of  the  constituent  to  be  introduced.  Examples 
with  and  without  the  introduction  of  extra  proteids  will  be 
given  : 

Single  feeding  :  i^oLidf  s~^. 

Quantity,  %2.     Formula  desired,  2.         .50     6. 

52  x  30  =  60  c.c.  x  .2=  12  c.c.,  decimal  cream,  adds,  2.         .50        .50 

Leaves,    0  0      5M 

32  x  30  =  60  c.c.  x  .55  =  33  c.c.  sugar  solution,  adds,  5.50 

Working  formula — 12  c.c.  decimal  cream. 

33  c.c.  standard  sugar  solution. 
15  c.c.  water. 
60  c.c. 

5— D.  C. 


66  FEEDING    OF  INFANTS. 

One  day's  food  :  ^7~?eJ  ^,nt  c ' 

°  Fat.  Proteids.  Sugar. 

Quantity,  535.     Formula  desired,  4.           1.       6.50 

5  35  x  30  =  1050  c.c.  x  .4  =  420  c.c.  decimal  cream,  adds,  4.          1 .       1 . 


Leaves,     0  0    .  5.50 

335  x  30  =  1050  c.c.  x  .55  =  577.50  c.c.  sugar  solution,  adds,  5.50 

Working  formula  — 420       c.c.  decimal  cream. 

577.50  c.c.  standard  sugar  solution. 
52.50  c.c.  water. 


Fat. 
4. 
4. 

—Per  cent. > 

Proteids.  Sugar. 

1.50        7. 
1.             1. 

0 

.50        6. 
.50         1.25 

0 

0        4.75 
4.75 

1050.00  c.c. 
One  feeding : 

Quantity,  5*5.     Formula  desired, 

^5  x  30  =  150  c.c.  x  .4  =  60.  c.c.  decimal  cream,  adds, 

Leaves,    0 
3*5  x  30  =  150  c.c.  x  -|  =  18.75  c.c.  skimmed  milk,  adds, 

Leaves,    0 
5*5  x  30  =100  c.c.  x  .475  =  71.75  c.c.  sugar  solution,  adds, 
Working  formula —  60        c.c.  decimal  cream. 

18.75  c.c.  saccharated  skimmed  milk. 
71.25  c.c.  standard  sugar  solution. 
15000  c.c. 

Other  methods  have  been  introduced  by  Holt  and  by  West- 
cott,  but  require  the  memorizing  of  algebraic  formulae  or  of 
certain  combinations,  while  this  method  of  Coit  is  the  sim- 
plest of  all,  really  requiring  no  memorizing,  as  the  whole 
process  can  be  deduced  from  the  formula?  for  milk-con- 
stituents. 

In  cities  where  milk  with  certain  definite  fat-percentages 
is  sold  a  less  exact  method  of  home  modification  and  one  not 
admitting  of  gradual  changes  of  the  constituents,  but  still 
of  practical  use  where  precision  is  not  specially  requisite,  is 
very  easy  to  adopt. 

The  so-called  8  per  cent,  milk  analyzes  :  proteids,  3.9  per 
cent. ;  fat,  8  per  cent.  ;  sugar,  4.3  per  cent. 

The  so-called  12  per  cent,  milk  analyzes :  proteids,  3.8 
per  cent.  ;  fat,  12  per  cent. ;  sugar,  4.2  per  cent. 

The  changes  in  the  sugar  and  proteids  are  so  small  that 
they  can  be  almost  overlooked,  especially  as  we  are  not  aim- 
ing at  marked  exactness. 

If  we  wish  a  milk  of  medium  proteid  strength,  we  choose 
the  12  per  cent,  milk,  and  dilute  it  with  twice  its  volume  of 


CONDENSED  MILK.  67 

sterile  water.  This  mixture  analyzes:  proteids,  1.26  per 
cent.;  fat,  4  per  cent.;  sugar,  1.4  per  cent.  If  to  this  we 
add  5  per  cent,  of  milk-sugar,  we  have  a  modified  milk  of 
fair  average  proportions. 

If  we  wish  a  milk  of  higher  proteld  strength,  we  choose 
the  8  per  cent,  milk,  and  dilute  it  with  an  equal  quantity  of 
sterile  water.  This  mixture  analyzes:  proteids,  1.95  per 
cent. ;  fat,  4  per  cent. ;  sugar,  2.15  per  cent.  Add  to  this  4 
per  cent,  of  milk-sugar,  and  we  get  a  stronger  milk  than 
before. 

By  making  slight  changes  in  the  proportions  of  water  and 
these  milks  we  can  modify  the  constituents  still  further. 
Here  again  the  addition  of  sodium  bicarbonate,  one  grain  to 
the  ounce,  or  of  lime-water,  1  :  20,  is  used  to  alkalinize  the 
milk. 

Cows'  milk — methods  of  examination :  The  reaction  and 
specific  gravity  should  be  taken  and  the  amount  of  fat  calcu- 
lated. Holt's  cream-tube  may  be  used;  but  it  is  not  so 
accurate  as  in  analyzing  breast-milk.  If  used,  the  cream 
should  be  made  to  rise  rapidly  by  standing  the  fresh  milk  on 
ice  for  about  eight  hours.  The  fat  is  now  about  one-fourth 
of  the  cream. 

The  best  optical  test  is  the  Feser  lactoscope.  It  depends 
on  the  obscuring  of  dark  lines  seen  through  the  milk  diluted 
with  more  or  less  water.  This  test  is  only  approximate,  and 
depends  too  much  on  individual  experience. 

The  most  accurate  and  quickest  method  is  by  means  of 
Babcock's  centrifugal  machine,  in  which  the  milk  is  mixed 
with  sulphuric  acid  and  then  revolved  rapidly  in  the  machine, 
the  fat  coming  to  the  top  of  the  narrow  tube  in  five  minutes 
and  being  read  off. 

So  far  there  is  no  clinical  method  for  estimating  the  pro- 
teids, this  requiring  the  work  of  a  skilled  chemist.  The  sugar 
is  fairly  uniform  at  4.5  per  cent. 

CONDENSED  MILK. 

Condensed  milk  is  made  by  evaporating  fresh  milk,  which 
has  been  sterilized  by  heat,  to  about  one-quarter  its  volume. 


68 


FEEDING    OF  INFANTS. 


After  this  it  is  preserved  by  adding  about  one-third  its  weight 
of  cane-sugar  before  being  sealed  in  the  cans.  In  many 
cities  fresh  condensed  milk,  without  the  addition  of  sugar,  is 
sold.  The  following  table  from  Holt  gives  the  composition 
of  condensed  milk,  and  of  dilutions  of  it  six,  twelve,  and 
eighteen  times  : 


Condensed 
Milk. 

Diluted 
6  times. 

Diluted 
12  times. 

Diluted 
18  times. 

Fat 

a            f  Cane-,  40.44 
SuSar    J  Milk-!  10.25  •    • 
Salts 

6.94 
8.43 

50.69 

1.39 
31.30 

.99 
1.20 

7.23 

.17 

90.49 

.53 

.65 

3.90 

.10 
94.82 

.36 

.44 

2.67 
.07 

96.46 

Condensed  milk  as  a  food :  The  dilution  of  twelve  parts  is 
nearest  that  ordinarily  used  for  infant-feeding.  A  study  of 
its  composition  as  diluted  thus  shows  that  the  infant  is  getting 
almost  no  fat,  a  quite  low  proteid  percentage,  about  the  right 
quantity  of  sugar,  and  altogether  too  little  salts.  The  total 
solids  lack  7  per  cent,  of  what  they  should  be.  Such  a  food 
is  easy  of  digestion,  but  decidedly  lacking  in  nutrition. 
Infants  thus  fed  have  as  a  rule  little  trouble,  if  any,  with 
their  digestion,  and  are  fat  and  plump  from  the  sugar,  but 
invariably  show  signs  of  more  or  less  rachitis,  depending  on 
the  length  of  time  the  condensed  milk  is  continued.  This 
latter  fact  seems  to  depend  on  the  lack  of  fat  and  salts,  and 
possibly  the  proteids  also.  Further,  these  children  although 
appearing  healthy  and  well  nourished,  have  very  little  resist- 
ing power  and  readily  succumb  to  acute  diseases. 

The  addition  of  cream  to  condensed  milk,  or  the  coincident 
use  of  cod-liver  oil,  will  prevent  these  bad  symptoms  from  its 
prolonged  use. 

Condensed  milk  has  some  marked  advantages  as  a  food  :  it 
is  sterile,  it  is  very  easy  and  simple  to  prepare,  and  it  is  very 
cheap.  As  a  temporary  food  to  bridge  over  sickness,  or  to 
use  in  travelling,  it  is  very  valuable  ;  but  it  ought  never  to 
be  used  for  any  length  of  time  unless  other  food  is  given 
with  it. 


INFANT  FOODS.  69 


INFANT  FOODS. 


Of  recent  years  a  large  number  of  proprietary  or  patent  or 
manufactured  foods  have  been  put  on  the  market  and  widely 
advertised  and  largely  used  for  feeding  infants.  They  are 
mostly  dried  powders,  intended  to  be  dissolved  in  water  for 
use.  It  is  quite  practical  to  divide  them  into  two  distinct 
classes  at  once  :  those  free  from,  and  those  containing,  un- 
changed starch. 

In  the  first  class  are  malted  milk  and  Mellin's  food ;  in  the 
latter  are  all  the  rest,  which,  having  raw  starch  as  a  constitu- 
ent, are  manifestly  unfit  for  infant  feeding  during  the  first 
nine  or  ten  months  of  life.  No  further  attention  will  be  paid 
to  these. 

Malted  milk  and  Mellin's  food  contain  no  ingredient  that  is 
objectionable  for  feeding,  but  are  lacking  in  one  of  the  import- 
ant ingredients  of  milk — the  fat,  and  contain  a  very  large 
excess  of  sugar.  Mellin's  food  is  recommended  to  be  dis- 
solved in  fresh  milk  to  overcome  partially  this  defect. 

Analyses  of  these  when  dissolved  in  about  the  amount  of 
water  in  milk  are  as  follows  : 

Malted  Milk.  Mellin's  Food. 

Fat, 39  per  cent.  .04  per  cent. 

Proteids,  .    .    .      2.28        "  1.50 

Sugar,  ....    10.18        "  11.56 

Salts, 5  "  .45 

Water,  ....   86.65        "  86.45 

Looking  over  these  analyses  we  find  about  a  normal  per 
cent,  of  proteids,  but  of  vegetable  and  not  animal  origin,  vir- 
tually no  fat,  and  a  great  excess  of  carbohydrates.  As  food 
they  often  produce,  like  condensed  milk,  fat,  plump  babies  ;  but 
these  infants  again  are  not  resistant  and  succumb  readily  to 
acute  diseases.  These  foods  are  often  well  digested,  and  are 
useful  at  times  as  temporary  foods  when  it  is  desirable  for  any 
reason  not  t<>  use  cows'  milk;  but  so  many  cases  of  both  rick- 
ets and  scurvy  have  been  traced  to  dried  foods  as  a  cause  that 
it  is  well    never  to  use  any  of  them   lor  any  great    length  of 


70  FEEDING   OF  INFANTS. 

time  without  using  simultaneously  some  fresh  food.  The 
addition  of  cream  to  either  does  away  with  the  lack  of  fat, 
and  adds  the  element  of  freshness  to  the  food,  but  what  value 
the  addition  of  the  food  to  fresh  cows'  milk  has,  is  as  yet 
unknown. 

During  the  second  yea?-  of  life  they  form  a  more  useful 
addition  to  an  infant's  dietary. 

Peptonized  milk :  This  is  milk  in  which  the  proteids  are 
changed  to  peptones,  or,  in  other  words,  digested,  by  the  addi- 
tion and  action  of  pancreatic  ferment.  The  process  may  be 
stopped  when  partially  performed,  giving  a  product  of  which 
the  taste  is  not  objectionable  ;  or  may  be  carried  on  to  com- 
plete peptonization,  when  the  product  has  a  very  bitter,  disa- 
greeable taste. 

Method  :  To  peptonize  milk  partially,  add  to  a  pint  of  fresh 
cows'  milk  and  four  ounces  of  water  five  grains  of  pancreatic 
extract  and  fifteen  grains  of  bicarbonate  of  soda.  Allow  this 
to  stand  at  a  temperature  of  105°  to  115°  F.  for  five  to  twenty 
minutes,  then  bring  to  a  boil  to  kill  the  ferment,  or  stand  on 
ice  to  prevent  its  further  action.  If  the  milk  is  to  be  used  at 
once,  neither  of  these  latter  is  necessary. 

To  peptonize  the  milk  completely,  allow  the  process  to  con- 
tinue for  one  to  two  hours.  After  this  time  the  addition  of 
acid  produces  no  coagulation. 

In  infant  feeding  it  is  better  to  peptonize  a  modified  than  a 
whole  milk.  Peptonized  milk  is  frequently  very  useful  in 
feeding  an  infant  with  feeble  digestive  powers;  but  it  is  un- 
wise to  continue  its  use  over  too  long  a  period,  as  then  the 
infant's  stomach,  being  called  on  to  do  no  work,  becomes  en- 
feebled from  disuse  and  gradually  unable  to  perform  its 
proper  function. 

Whey :  By  coagulating  one  pint  of  fresh  milk  by  adding  a 
teaspoonful  of  essence  of  pepsin,  and  allowing  this  to  stand, 
a  solid  curd  is  formed  swimming  in  a  liquid — whey.  This 
has  the  following  composition  :  proteids,  .86  per  cent. ;  fat, 
.32  per  cent. ;  sugar,  4.79  per  cent. ;  salts,  .65  per  cent. ; 
water,  93.38  per  cent. 

This  at  times  makes  a  very  valuable  food  for  infants  in 
cases  of  gastric  or  intestinal  disorder,  where  the  use  of  milk 


INFANT  FOODS.  71 

must  for  a  time  be  interdicted.  Babies  like  it,  it  is  very 
easy  of  digestion,  and  does  not  irritate  the  stomach.  A  little 
wine  may  be  added  if  desired. 

Egg-water :  This  is  made  by  mixing  thoroughly  the  white 
of  one  egg  with  six  ounces  of  water  and  adding  a  little  salt. 
The  addition  of  a  few  grains  of  sugar  will  make  the  child 
take  it  better,  and  adds  also  a  food-element. 

Such  a  mixture  is  one  of  the  best  foods  we  have  for  tem- 
porarily feeding  an  infant  with  digestive  disturbances  when 
we  wish  for  a  time  to  stop  temporarily  all  milk  food. 

Beef-juice :  Expressed  beef-juice  is  obtained  by  slightly 
broiling  a  piece  of  lean  beef,  and  then  squeezing  the  juice 
from  it  by  a  lemon-squeezer.  One  pound  of  steak  yields  two 
or  three  ounces  of  juice.  This  is  flavored  with  salt  and 
given  cold  or  warm.  Do  not  heat  enough  to  coagulate  the 
albumin.  This  is  very  nutritious  and  usually  well  taken.  It 
may  be  given  at  the  rate  of  a  tablespoonful  three  times  a  day. 

Scraped  beef:  This  is  another  valuable  and  easily  digested 
food.  It  is  prepared  by  scraping  with  a  dull  knife  some  raw 
or  rarely  done  lean  beef.  A  tablespoonful  of  this  salted  is 
the  amount  usually  given  at  a  feeding. 

Broths :  These  are  made  by  first  soaking  and  then  boiling 
one  pound  of  lean  beef,  mutton,  veal,  or  chicken,  in  one  pint 
of  water.  They  do  not  contain  a  large  quantity  of  nourish- 
ment, but  do  have  in  them  many  extractives,  and  hence  are 
stimulating  rather  than  nutritious. 

Barley-,  oatmeal-,  or  rice-water :  These  are  made  by  boiling 
an  ounce  of  barley,  oatmeal,  or  rice  in  a  quart  of  water  to  a 
pint,  and  straining  before  use. 

Feeding  in  the  second  year  :  During  the  second  year  a  child 
should  have  five  meals  a  day,  about  7  and  10  A.  M.  and  1,  4, 
and  7  p.  m.,  and  nothing  between  meals.  A  sample  diet  is  as 
follows  :  7  a.  m.,  a  tablespoonful  of  some  well-boiled  cereal — 
wheat,  rice,  oatmeal,  barley,  or  hominy,  with  cream  and  a 
little  sugar  if  necessary;  10  a.m.,  a  half  pint  of  milk; 
1  I".  >F.,  tablespoonful  of  scraped  beef,  or  soft-boiled  egg, 
piece  of  dry  bread,  ;i  half  pint  of  milk  ;  4  p.  m.,  a  half  pint 
of   milk;    7    P.    m.,    a    tablespoonful   of  cereal    with    cream 


72  FEEDING   OF  INFANTS. 

and  sugar;    a  little  orange  juice  may  be  given  from   time 
to  time. 

Feeding  in  the  third  and  fourth  years  :  During  this  time  four 
daily  meals  are  sufficient,  at  7  and  10.30  a.  m.  and  1.30  and 
6  p.  m.,  and  again  nothing  should  be  given  between  meals. 
A  sample  diet  is  as  follows  :  7  a.  m.,  orange,  cereal  with 
cream  and  sugar,  glass  of  milk ;  10.30  A.  M.,  glass  of  milk 
or  cup  of  broth  and  slice  of  stale  bread  or  toast  or  zwiebach ; 
1.30  P.  M.,  piece  of  meat — steak,  chop,  or  chicken — two  vege- 
tables, potatoes  and  spinach,  rice  or  bread  pudding,  or  prunes, 
or  apple  sauce ;  6  p.  m.,  bread  and  milk,  or  milk  toast. 


CHAPTER    VI. 

DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

DISEASES   OF   THE   MOUTH. 

CATARRHAL  STOMATITIS. 

Definition :  This  is  a  simple  catarrhal  inflammation  of  the 
mucous  membrane  of  the  mouth,  unaccompanied  by  ulcera- 
tion. 

Etiology :  Irritants  taken  into  the  mouth,  as  too  hot  fluids, 
dirty  teething-rings,  sugar-teats,  or  substances  the  child  may 
pick  up  from  the  floor,  are  active  causes.  It  is  at  times 
started  by  excessive  or  rough  efforts  at  cleanliness.  It  com- 
plicates the  infectious  diseases,  as  measles,  scarlet  fever,  diph- 
theria, or  influenza.  The  eruption  of  the  teeth  may  at  times 
produce  it. 

Pathology :  There  is  congestion,  accompanied  by  desqua- 
mation of  the  buccal  epithelium.  This  is  followed  by  in- 
creased secretion  of  the  mucous  and  salivary  glands. 

Catarrhal  stomatitis — symptoms  :  The  mucous  membrane  of 
the  mouth  is  red,  swollen  ;  at  first  hot  and  dry,  later  bathed 
in  a  profuse  secretion.  The  temperature  is  slightly  elevated, 
the  child  is  restless  and  fretful.  The  mouth  is  tender,  as 
shown  by  marked  evidences  of  pain  when  anything  is  put 
into  the  mouth  or  on  examination.  In  severe  eases  the  child 
refuses  food.  At  times  the  inflammation  may  be  severe 
enough  to  produce  a  slightly  blood-stained  secretion.  The 
tongue  is  coated  on  the  surface  and  reddened  on  the  r(\o;c<. 
The  neighboring  lymphatic  glands  may  be  enlarged  and 
tender. 

Prognosis:  This  is  good.  The  duration  depends  on  the 
cause. 

Catarrhal  stomatitis — treatment:   Remove  the  cause,  if  it 

73 


74  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

can  be  found.  Attend  to  the  general  hygiene  and  diet.  Use 
frequently  gentle  antiseptic  cleansing  of  the  mouth  with  cold 
washes  of  saturated  solution  of  boric  acid,  or  borax  2  per 
cent.  In  the  severer  cases  a  daily  application  of  a  1  per  cent, 
nitrate  of  silver  solution  will  hasten  the  cure. 


FOLLICULAR  STOMATITIS. 

Synonyms  :  This  is  also  called  aphthous  and  herpetic  stom- 
atitis from  the  formation  of  small  vesicles,  which  later  form 
superficial  ulcers.  These  ulcers  at  first  are  discrete,  but  may 
coalesce  into  larger  ones.  They,  however,  always  remain 
superficial. 

Etiology :  There  seems  to  be  a  reflex  nervous  origin  of  this 
form  of  stomatitis,  similar  to  that  seen  in  connection  with 
herpes  elsewhere.  Gastro-intestinal  disorders  and  dentition 
seem  to  be  factors  of  this  sort.  The  cause  is  more  frequently 
general  than  local. 

Pathology :  On  the  mucous  membrane  of  the  cheeks  or  lips, 
or  the  edges  of  the  tongue,  but  not  in  the  gums,  there  are 
present  pearl-colored  vesicles,  about  the  size  of  a  pin's  head, 
and  later  small  ulcers  formed  by  abrasion  of  the  epithelial 
covering  of  these  vesicles.  More  or  less  catarrhal  stomatitis 
is  always  associated. 

Follicular  stomatitis — symptoms :  The  symptoms  resemble 
those  of  catarrhal  stomatitis,  but  are  more  marked.  There 
are  fever,  furred  tongue,  heat,  redness,  swelling,  pain,  and  in- 
creased secretion.  The  mouth  presents  the  appearance  de- 
scribed of  vesicles  and  superficial  ulcers,  and  in  addition 
general  redness.  The  lymphatic  glands  of  the  neck  are 
swollen  and  tender. 

Prognosis  :  This  is  good.  It  is  a  self-limited  disease ;  but 
if  improperly  managed,  may  go  on  to  ulcerative  stomatitis. 

Follicular  stomatitis — treatment :  Regulate  the  diet  and 
general  condition  of  the  patient.  Bathe  the  mouth  frequently 
with  solution  of  potassium  permanganate,  grains  three  to  the 
ounce.  Chlorate  of  potassium  given  internally,  grains  two 
every  three  hours,  well  diluted,  has  repute  with  some.  Solid 
silver  nitrate  may  be  applied  to  the  ulcers. 


ULCERATIVE  STOMATITIS.  75 


ULCERATIVE  STOMATITIS. 

Definition  :  This  form  of  stomatitis  is  only  seen  with  the 
presence  of  teeth,  and  consists  in  an  ulcerative  process  begin- 
ning in  the  mucous  membrane  of  the  gums  around  the  teeth, 
and  spreading  from  this  point  to  the  rest  of  the  mouth.  It 
is  accompanied  by  a  peculiar  fetor  of  the  breath. 

Etiology  :  Overuse  of  mercury,  decayed  teeth,  improper 
food,  bad  hygiene,  exhausting  diseases,  and  scurvy  are  fre- 
quent causes.     It  is  often  a  sequel  of  the  infectious  diseases. 

Pathology  :  The  process  begins  around  a  tooth  and  involves 
the  gum  and  the  contiguous  surfaces  of  the  lips,  cheek,  and 
edges  of  the  tongue.  The  mucous  membrane  is  much  swollen 
and  of  a  deep  livid  hue.  The  ulceration  may  extend  deeply 
to  the  periosteum  and  cause  necrosis  of  the  maxilla.  The 
ulcerative  process  never  extends  beyond  the  mouth. 

Ulcerative  stomatitis — symptoms  :  These  are  pain,  fretful- 
ness,  change  in  disposition,  crying,  and  wakefulness.  There 
is  an  increase  in  the  buccal  secretions,  to  which  there  is  a 
foetid  odor.  The  mouth  and  gums  bleed  frequently.  On  in- 
spection the  gums  are  swollen,  spongy,  livid,  and  bleed  easily. 
A  line  of  ulceration,  with  a  white  necrotic  appearance,  will 
be  found  around  one  or  more  of  the  teeth.  In  severe  cases 
the  teeth  may  be  loosened  and  sequestra  of  bone  found.  The 
submaxillary  lymphatic  glands  are  badly  swollen  and  painful. 
The  tongue  is  swollen,  thickly  coated,  and  shows  the  indenta- 
tion of  the  teeth  on  the  edges. 

Prognosis:  If  left  to  itself,  the  disease  progressively  in- 
creases, the  ulceration  extending  further  and  further  until  a 
frightful  condition  of  the  mouth  results.  Gangrenous  stoma- 
titis may  supervene.  If  properly  treated  in  the  early  stages, 
a  rapid  cure  results;  and  even  when  further  advanced  treat- 
ment is  very  efficacious. 

Ulcerative  stomatitis — treatment :  First  remove  the  cause 
by  stopping  the  use  of  mercury,  improving  the  hygienic  sur- 
roundings, and  treating  the  scorbutus  if  present.  Keep  the 
mouth  scrupulously  clean  by  frequent  washings  with  peroxide 
of  hydrogen  or  permanganate  of  potassium.  If  there  is  much 
bleeding,  a  solution  of  alum  is  useful,     [nternally,  chlorate  of 


76  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

potassium  is  almost  a  specific,  being  excreted  after  absorption 
by  the  buccal  mucous  membrane.  It  is  best  given  at  the  rate 
of  two  grains,  largely  diluted,  every  two  hours.  If  under  this 
form  of  treatment  the  ulcers  do  not  heal,  some  of  the  teeth 
may  need  extracting,  as  a  sequestrum  is  probably  present. 
The  ulcers  may  heal  faster  under  daily  pencillings  with  silver 
nitrate  in  stick-form. 

THRUSH. 

Etiology  :  This  form  of  stomatitis  is  caused  by  the  presence 
and  growth  in  the  mouth  of  a  fungus  called  the  saccharomyces 
albicans.     It  is  a  parasite  of  the  class  of  yeast  fungus. 

The  fungus  is  the  only  cause,  but  it  never  grows  except  on  a 
previously  unhealthy  mucous  membrane.  It  develops  spe- 
cially in  feeble,  badly  nourished,  and  marasmic  infants,  and 
in  those  suffering  from  gastro-intestinal  diseases.  The  use  of 
improper  food,  uncleanliness  of  the  mouth,  fermentation  of 
particles  of  food,  or  a  previous  catarrhal  stomatitis  favors  its 
growth.  Under  favorable  conditions  the  fungus  will  grow  on 
any  of  the  mucous  membranes  of  the  body.  The  spores  are 
conveyed  to  the  mouth  usually  by  dirty  nipples,  sugar-teats, 
and  such  like,  but  may  spread  through  the  atmosphere. 

Pathology :  The  parasite  consists,  microscopically,  of  long 
threads  (the  mycelium)  interwoven  together,  and,  in  their 
"  meshes,"  oval  bodies  (the  spores).  The  fungus  lodges  on  the 
mucous  membrane  of  the  mouth  and  grows  in  little  clumps 
of  white  between  the  epithelial  cells,  thence  spreading  to 
the  surface.  These  white  tufts  may  be  scattered  uniformly 
all  through  the  mouth,  and  many  may  coalesce  into  larger 
lumps.  They  seldom  produce  pus.  The  mucous  membrane 
of  the  mouth  is  the  seat  of  catarrhal  stomatitis. 

Thrush — symptoms :  The  subjective  symptoms  are  very 
slight.  The  appearance  of  the  mouth  is  very  characteristic. 
The  whole  mouth,  or  only  parts,  is  studded  with  little  white 
feathery  spots,  seeming  to  rise  above  the  surface  of  the 
mucous  membrane,  and  which  do  not  rub  off  with  ease,  but 
leave  a  bleeding  spot  behind.  They  appear  first  on  the 
tongue  and  cheeks,  but  may  spread  to  the  lips,  palate,  tonsil, 
and  pharynx,  and  at  times  to  the  oesophagus  and  stomach. 


GANGRENOUS  STOMATITIS.  77 

Each  spot  has  the  appearance  of  a  little  lump  of  coagulated 
milk,  but  is  differentiated  from  this  by  the  difficulty  of 
removal.  These  cases  usually  have  acrid,  irritating  stools 
with  erythema  of  the  buttocks. 

Prognosis :  It  is  not  in  itself  a  serious  disease,  but  so  often 
appears  in  a  much  debilitated  child  that  it  is  associated  in  the 
lay  mind  with  severe  cases.  If  properly  treated  in  a  child 
strong  enough  to  withstand  the  original  disease,  thrush  is 
always  recovered  from. 

Treatment :  Thrush  may  almost  always  be  prevented  by 
thorough  cleanliness  of  nipples,  bottles,  and  mouth.  If 
present,  the  disease  is  treated  by  the  use  of  an  antiseptic 
mouth-wash,  the  best  of  which  is  a  solution  of  boric  acid  in 
glycerin,  grains  ten  to. the  ounce,  applied  four  times  a  day 
with  a  soft  rag  or  camel's-hair  brush.  Special  attention 
should  be  paid  to  remedy  any  underlying  condition. 

GANGRENOUS   STOMATITIS. 

Definition :  This  disease  is  also  called  noma  and  cancrum 
oris,  and  consists  essentially  of  a  gangrene  beginning  in  the 
mucous  membrane  of  the  gums,  cheeks,  or  lips,  spreading 
rapidly,  and  destroying  all  the  tissue  it  attacks. 

Etiology :  It  is  usually  a  secondary  disease  following 
measles,  whooping-cough,  chronic  intestinal  catarrhs,  or 
general  sepsis.  It  seems  never  to  develop  in  previously 
healthy  children.  At  times  it  supervenes  on  ulcerative 
stomatitis.  Streptococci  are  found  in  most  of  the  cases,  but 
no  specific  germ  has  as  yet  been  isolated. 

Pathology  :  The  mucous  membrane  first  presents  a  brawny 
induration,  followed  by  a  sloughing  ulcer.  This  induration 
extending  to  the  skin  gives  rise  to  a  livid,  glazed  appearance 
in  the  integument,  which  later  becomes  black,  and  perforation 
of  the  cheek  follows.  The  sloughing  process  may  extend  and 
involve  the  whole  side  of  the  face  and  the  bones  of  the  jaw. 
The  vessels  become  thrombosed  and  hemorrhage  is  rare.  A 
line  of  demarcation  rarely  forms,  but  the  gangrene  steadily 
spreads  till  death  ensues. 

Symptoms  :    The  constitutional   symptoms   of   gangrenous 


78  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

stomatitis  are  those  of  great  prostration  and  sepsis,  being 
more  or  less  marked  at  the  beginning,  but  rapidly  increasing 
in  severity  as  the  disease  progresses.  The  temperature  runs 
from  102°  to  105°  F.  The  pulse  is  rapid  and  feeble,  the 
appetite  is  lost,  and  a  severe  diarrhoea  is  frequent.  Septic 
pneumonia  frequently  supervenes. 

Locally,  in  the  early  stages  there  is  moderate  pain,  but  it  is 
never  very  marked.  The  typical  appearance  of  the  ulcera- 
tion spreads  in  all  directions  from  its  starting-point,  and  a 
gangrenous  odor  is  present  in  the  breath.  The  secretions  of 
the  mouth  are  increased  in  quantity,  and  soon  become  thick 
and  sanious.  The  gangrene  may  involve  the  whole  cheek,  the 
eyelids,  and  even  the  eye.  The  appearance  is  one  of  the 
most  repulsive  ever  seen.  The  duration  of  the  disease  is  one 
to  two  weeks. 

Prognosis :  This  is  very  bad,  fully  three-fourth's  of  the 
cases  dying. 

Gangrenous  stomatitis — treatment :  Support  the  patient's 
strength  with  nutritious  food,  stimulants,  and  tonics.  Locally, 
the  necrotic  area,  as  soon  as  a  diagnosis  is  made,  should  be 
freely  destroyed,  under  the  influence  of  an  anesthetic,  by  the 
actual  cautery.  The  cauterization  should  go  well  beyond  the 
diseased  into  the  healthy  tissue.  If  new  gangrenous  spots 
appear,  these  should  be  treated  in  the  same  way.  The  wound 
should  be  dressed  afterward  with  strong  antiseptics  and  the 
mouth  kept  very  clean  by  the  use  of  peroxide  of  hydrogen. 


CROUPOUS  STOMATITIS. 

Definition :  This  is  the  form  of  stomatitis  in  which  the 
buccal  mucous  membrane  undergoes  an  inflammatory  process 
accompanied  by  the  production  of  a  false  membrane.  It  is 
also  called  diphtheritic  stomatitis. 

Etiology:  Intense  chemical  irritants  may  rarely  form  a 
false  membrane  ;  but  the  large  majority  of  the  cases  are  due 
to  the  growth  on  the  buccal  mucous  membrane  of  the  Klebs- 
Loffler  bacillus.  In  the  mouth  it  is  almost  invariably  second- 
ary to  the  presence  of  diphtheritic  membranes  elsewhere,  as 


ADHMSIA    LINGUjE—RANULA.  79 

on  the  tonsils  or  pharynx  ;  but  the  month  may  possibly  be 
the  primary  seat. 

Pathology :  There  is  a  stomatitis  affecting  the  lips  and 
cheeks  which  is  accompanied  by  the  growth  on  these  inflamed 
parts  of  a  pseudo-membrane,  which  is  firmly  adherent  to  its 
seat. 

The  symptoms  of  croupous  stomatitis  are  usually  those  of 
the  primary  diphtheria,  with  the  addition  of  sore,  tender 
mouth.  Diphtheria  of  the  mouth  always  belongs  to  the 
severe  cases  of  the  disease. 

Croupous  stomatitis — treatment :  The  primary  diphtheria  is 
to  be  treated  as  always,  and  the  mouth  by  frequent  and  gentle 
cleansing  with  a  saturated  solution  of  boric  acid.  The  mem- 
brane should  not  be  forcibly  removed. 

ADHMSIA  LINGILE. 

This  condition,  commonly  known  as  tongue-tie,  consists  of 
an  abnormally  short  frsenum.  It  may  interfere  with  suckling, 
and  later  may  possibly  affect  the  speech,  but  is  not  nearly  so 
important  as  is  commonly  supposed. 

Treatment :  Strip  the  frsenum  near  its  attachment  to  the 
tongue  with  a  pair  of  scissors,  and  then  tear  the  cut  deeper 
by  a  dull  instrument,  as  the  finger-nail. 

RANULA. 

Definition  :  This  is  a  cyst,  forming  in  the  floor  of  the  mouth 
on  either  side  of  the  frsenum.  It  varies  in  size,  but  may  be- 
come large  enough  to  interfere  seriously  with  the  uses  of  the 
njouth.  It  is  clue  to  occlusion  of  a  mucous  duct,  or  the  duct 
of  the  sublingual  gland.  The  cyst  may  be  simple  or  multi- 
locular. 

Symptoms:  This  growth  is  painless,  fluctuates,  and  is  the 
color  of  the  buccal  mucous  membrane.  The  fluid  it  contains 
is  a  glairy  mucus. 

Ranula — treatment— Snip  off  the  top  of  the  cyst-wall, 
evacuate  the  fluid,  and  cauterize  the  interior  of  the  sac  with 
solid  nitrate  of  silver  or  iodine. 


80  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

ALVEOLAE  ABSCESS. 

Definition :  This  is  fairly  common  in  children  with  teeth 
allowed  to  be  kept  in  a  state  of  decay  or  uncleanliness.  It 
consists  of  an  inflammation  going  on  to  the  production  of  pus 
beginning  around  the  roots  of  a  tooth.  The  periosteum  of 
the  jaw  may  be  involved,  and,  if  neglected,  necrosis  of  the 
jaw  may  result. 

Alveolar  abscess — symptoms  :  There  is  pain  in  the  affected 
part,  with  fever  and  other  constitutional  symptoms.  The 
face  is  always  badly  swollen  on  the  outside,  and  in  the  mouth 
is  a  similar  condition.  After  the  formation  of  pus  fluctua- 
tion can  be  made  out  within  the  mouth.  The  pus  may  per- 
forate into  the  antrum,  if  in  the  upper  jaw,  or  will  discharge 
through  the  buccal  mucous  membrane  or  the  skin,  if  left 
alone. 

Alveolar  abscess — treatment :  The  teeth  should  be  kept 
clean  by  the  use  of  a  tooth-brush,  and  decayed  fangs  should 
be  extracted.  If  the  abscess  begins  to  form,  it  should  be 
hastened  by  the  use  of  hot  applications  in  the  form  of  poul- 
tices externally  and  hot  washes  in  the  mouth.  As  soon  as 
pus  is  detected  the  abscess  should  be  lanced  from  within  the 
mouth  (to  prevent  cutaneous  scars),  the  pus  evacuated,  and 
the  cavity  well  drained  and  packed. 

DISEASES   OF   THE    THROAT. 

ACUTE  PHARYNGITIS. 

Pathology :  In  this  condition  the  whole  pharynx  and  the 
tonsils  are  inflamed  and  red.  It  may  be,  and  frequently  is,  a 
primary  disease ;  or  it  may  be  part  of  one  of  the  infections, 
as  scarlet  fever,  measles,  diphtheria,  or  influenza. 

Etiology :  It  is  most  commonly  caused  by  exposure  to  cold, 
but  probably  behind  this  is  some  bacterial  invasion.  The 
disease  at  times  appears  infectious.  A  rheumatic  diathesis  is 
frequently  present.  Certain  individuals  present  a  marked 
predisposition  and  have  recurrent  attacks. 

The  symptoms  of  acute  pharyngitis  are  pain  in  swallow- 
ing and  dryness  in  the  throat,  with  later  an  increase  in  the 


RETRO-PHARYNGEAL  ABSCESS.  81 

secretion.  There  is  frequently  an  irritating  purposeless 
cough.  On  examination  the  soft  palate,  uvula,  tonsils,  and 
pharynx  are  seen  to  be  red  and  inflamed.  The  posterior  sur- 
face of  the  soft  palate  is  often  attacked  early  and  the  whole 
naso-pharynx  involved. 

The  constitutional  symptoms  may  be  marked,  with  rise  of 
temperature  at  times  to  103G  F.,  and  its  accompanying  symp- 
toms.    Vomiting  may  be  present. 

Diagnosis :  This  is  easy  from  the  inspection  of  the  throat ; 
but  we  should  never  forget  the  possibility  of  the  pharyngitis 
being  the  initial  lesion  of  one  of  the  infectious  diseases. 

Acute  pharyngitis — treatment :  The  bowels  should  be 
opened  by  fractional  doses  of  calomel  frequently  repeated. 
Small  doses  of  phenacetin  given  every  three  hours  will  re- 
duce the  fever,  ease  the  pain,  and  give  general  comfort  to  the 
patient. 

Locally,  the  throat  should  at  short  intervals  be  sprayed  or 
swabbed,  or  the  naso-pharynx  washed  out,  according  as  the 
child  is  old  enough  to  allow  one  or  the  other  method  of  appli- 
cation. Some  mild  alkaline  wash,  such  as  Seder's  solution, 
seems  the  best. 

Chronic  pharyngitis :  This  is  a  rare  condition  in  childhood, 
but  may  develop  as  the  result  of  frequent  attacks  of  the  acute 
form.  One  of  its  common  results  is  to  produce  an  elonga- 
tion of  the  uvula.  With  this  is  associated  an  harassing  cough, 
from  the  uvula  tickling  the  base  of  the  tongue  by  its  con- 
stant presence. 

Treatment:  Astringent  local  applications  are  useful  in  this 
condition,  but  amputation  of  the  tip  of  the  uvula  may  be 
required  for  cure. 

RETRO-PHARYNGEAL  ABSCESS. 

Definition:  In  this  disease  a  collection  of  pus  makes  its 
appearance  in  the  posterior  pharyngeal  wall.  In  a  general 
way  there  are  two  sources  of  this  pus:  either  from  a  suppu- 
rative inflammation  of  the  connective  tissue,  or  of  a  lymphatic 
gland,  of  the  posterior  pharyngeal  wall  ;  or  from  caries  of 
the  cervical  vertebras.  What  is  ordinarily  understood  by  retro- 
6— D.  c. 


82  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

pharyngeal  abscess  is  the  former  variety — i.  e.,  that  without 
disease  of  the  bone. 

Retro-pharyngeal  abscess — etiology :  The  cause  usually  lies 
in  an  infection  of  the  lymphatics  from  a  precedent  inflamma- 
tion of  the  nose  or  pharynx.  The  disease  is  regularly  one  of 
infancy,  and  infants  are  particularly  prone  to  adenitis.  The 
disease  is  most  frequent  in  winter  and  spring,  when  diseases 
of  the  nose  and  throat  are  commonest.  It  may  follow  an 
attack  of  influenza,  or  more  rarely  scarlatina  or  measles.  It 
is  usually  seen  only  in  delicate  children. 

Pathology:  The  simple  form  is  primarily  a  suppurative  in- 
flammation of  one  or  more  of  the  lymphatic  glands  lying 
just  in  front  of  the  cervical  vertebrae.  The  inflammation 
spreads  to  and  involves  the  cellular  tissue.  Some  few  cases 
never  go  on  to  the  formation  of  pus.  In  the  form  due  to 
cervical  caries  a  much  more  serious  condition,  with  broken- 
down  bone,  is  present. 

Retro-pharyngeal  abscess — symptoms  :  The  three  symptoms 
of  most  importance  are  stiff  neck,  dysphagia,  and  dyspnoea. 
This  dyspnoea  may  come  on  in  sudden  attacks  and  appear 
quite  alarming.  The  temperature  is  raised  to  102°  F.,  and 
the  child  is  usually  sick  for  five  or  six  days  before  the  abscess 
develops. 

The  diagnosis  is  made  by  a  careful  ocular  and  digital  ex- 
amination. A  fluctuating  swelling  is  found  directly  in  front 
of  the  bodies  of  the  vertebras,  but  a  little  to  one  or  the  other 
side.  The  mucous  membrane  of  the  soft  palate  is  usually 
red  and  swollen.  There  may  be  a  tumor  at  the  angle  of  the 
jawr  on  the  same  side. 

Prognosis  :  The  abscess,  if  left  to  itself,  usually  ruptures  in 
the  course  of  a  week  or  two.  The  pus  may  be  swallowed  or 
expectorated.  If  rupture  does  not  occur,  the  pus  may  burrow 
in  the  neck.  Fatal  cases  may  occur  from  stoppage  of  the 
respiration  or  the  bursting  of  the  abscess  into  the  larynx. 
If  properly  treated,  rapid  recovery  is  the  rule. 

The  cases  due  to  spinal  caries,  of  course,  take  their  progno- 
sis from  this,  the  underlying  factor. 

Retro-pharyngeal  abscess — treatment :  The  formation  of  pus 
should  be  hurried  by  hot  applications  to  the  neck.     As  soon 


ADENOIDS  OF  THE  NASO-PHARYNX.  83 

as  fluctuation  is  made  out,  prompt  incision  should  be  made. 
The  child  should  be  upright,  and  the  abscess  freely  opened  at 
its  lowest  point,  the  child's  head  being  bent  forward  quickly 
to  allow  escape  of  the  pus.  The  opening  may  be  made  by  a 
protected  knife,  a  pair  of  dressing-forceps,  or  the  finger-nail. 
After-treatment  is  usually  unnecessary. 

ADENOIDS  OF  THE  NASO-PHARYNX. 

Definition :  This  is  a  hypertrophy  of  the  so-called  third  or 
pharyngeal  tonsil,  a  mass  of  adenoid  tissue  located  in  the 
naso-pharynx,  just  below  the  basilar  portion  of  the  occipital 
bone. 

Etiology :  There  seems  to  be  a  predisposition  in  some  chil- 
dren to  overgrowth  of  the  lymphatic  structures  of  the  body. 
The  diathesis  is  congenital,  but  the  disease  seems  to  be  ac- 
quired. Delicate  children  are  most  frequently  affected. 
Damp,  changeable  climates  seem  to  predispose  to  it.  It  may 
follow  attacks  of  the  infectious  diseases. 

Pathology :  The  growths  are  a  simple  hypertrophy  of  the 
natural  tissue  of  the  third  tonsil  due  to  folding  in  and  over 
of  the  mucous  membrane  covering  it.  They  are  attached  to 
the  bone  above  and  behind. 

The  symptoms  of  adenoids  are  mainly  the  result  of  the 
accompanying  chronic  naso-pharyngeal  catarrh,  plus  the 
mechanical  obstruction  of  the  growths  to  the  breathing.  The 
catarrh  is  evidenced  mainly  by  a  persistent  discharge  from 
the  nose,  growing  better  or  worse  with  changes  in  the  weather, 
but  always  persisting.  There  is  great  difficulty  in  blowing 
the  nose  and  clearing  out  this  discharge.  Attacks  of  otitis 
are  frequent  and  recurrent.  Sleeping  is  interfered  with  and 
nervous  symptoms  are  prominent,  such  as  dreams,  night- 
terrors,  and  somnambulism. 

The  obstructive  symptoms  are  mouth-breathing,  snoring 
during  sleep,  a  nasal  voice,  and  deafness  from  occlusion  of 
the  Eustachian  tubes.  The  persistent  mouth-breathing  pro- 
duces  a  typical  shape  of  the  face,  with  a  pinched  nose,  and 
deflected  septum,  a  prominent  pointed  upper  jaw  with  mis- 
placed   teeth;    a   high-peaked    hard    palate,   and   a   deficient 


84  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

lower  jaw.  The  whole  expression  of  the  face  is  characteris- 
tic and  very  stupid.  In  fact,  these  children  are  stupid,  their 
mental  condition  usually  being  below  par.  The  chest  is 
apt  to  be  deformed  or  pigeon-breasted. 

Adenoids — prognosis:  They  have  a  tendency  to  increase 
till  puberty,  when  a  spontaneous  atrophy  seems  to  occur,  the 
enlargement  of  the  naso-pharyngeal  space  itself  giving  in- 
creased room  for  them.  The  deformities  produced  and  the 
evils  done  by  their  presence,  however,  never  disappear,  but 
remain  as  a  handicap  for  life.  Patients  with  adenoids  are 
prone  to  diphtheria,  and  have  more  severe  attacks  of  it  than 
normal  children.  The  same  is  true  of  others  of  the  infectious 
diseases. 

Adenoids — treatment :  The  only  adequate  treatment  is 
operative  removal  of  the  growths.  This  is  best  done  under 
full  anaesthesia  with  the  use  of  a  mouth-jag,  using  the  adenoid 
forceps  first,  and  cleaning  out  the  ragged  remnants  afterward 
by  a  Gottstein's  curette.  The  head  can  be  held  so  as  to  pre- 
vent blood  from  running  down  the  trachea.  There  is  no 
especial  after-treatment,  and  the  results  of  the  operation  are 
very  brilliant.  Recurrence  is  rare.  The  syrup  of  the  iodide 
of  iron  may  be  given  to  build  up  the  health  afterward. 

ACUTE  FOLLICULAR  TONSILLITIS. 

Definition :  This  is  the  form  of  acute  inflammation  attack- 
ing and  confined  to  the  tonsils  proper.  It  is  called,  wrongly, 
diphtheritic  sore  throat. 

Acute  follicular  tonsillitis — etiology :  It  is  undoubtedly  an 
infectious  disease  due  to  the  presence  in  the  tonsillar  crypts 
of  some  form  of  streptococcus  or  staphylococcus.  There  is 
a  very  marked  predisposition  in  some  children  to  attacks  of 
this  disease.  A  rheumatic  diathesis  seems  a  predisposing 
factor.  Those  with  chronic  hypertrophy  of  the  tonsils  are 
often  the  victims.  "  Catching  cold "  is  often  the  exciting 
cause. 

Pathology :  The  infection  begins  in  the  mucous  membrane 
at  the  bottom  of  the  tonsillar  crypts.  The  crypt  is  soon  filled 
with  a  whitish  plug  of  pus,  fibrin,  and  epithelium,  which  pro- 


PERITONSILLAR  ABSCESS.  85 

jects  from  the  surface  of  the  tonsil.  The  separate  crypts  being 
tilled  the  same  way,  give  a  white  spotted  appearance  to  the 
whole  tonsil.  The  contents  of  one  or  more  crypts  may 
coalesce.  The  whole  tonsil  is  much  swelled  and  inflamed. 
The  disease  is  bilateral. 

Acute  follicular  tonsillitis — symptoms :  The  disease  begins 
suddenly  with  chilly  sensations,  a  rapid  rise  of  temperature 
to  102°  to  104°  F.,  and  marked  general  malaise  with  head- 
ache and  backache.  Pain  in  the  throat  of  quite  a  severe 
type  follows,  made  worse  by  swallowing.  The  severe  symp- 
toms last  three  or  four  days.  The  glands  at  the  angle  of  the 
jaw  are  inflamed,  swollen,  and  tender. 

On  inspection,  at  first  the  tonsils  appear  red  and  swollen, 
but  the  characteristic  white  spots  soon  make  their  appearance. 
In  differentiating  them  from  diphtheria  it  is  to  be  observed 
that  these  spots  can  be  easily  rubbed  off  with  a  swab,  and 
when  removed  leave  no  bleeding  spot  behind  as  is  the  case  in 
diphtheria.  Tonsillitis  is  also  much  more  sudden  in  its  onset. 
The  exudate  in  tonsillitis  never  appears  elsewhere  than  on 
the  tonsils.  It  may  be  necessary  to  make  a  culture  to  prove 
the  presence  or  absence  of  Klebs-Loffler  bacilli. 

Prognosis :  This  is  good,  as  recovery  occurs  even  without 
treatment. 

Acute  follicular  tonsillitis — treatment :  A  combination  of 
small  doses  of  phenacetin  and  sodium  salicylate,  five  grains 
of  each  given  every  four  hours,  has  a  very  comfortable  effect, 
alleviating  the  fever  and  many  of  the  unpleasant  constitu- 
tional symptoms.  Locally,  a  gargle  or  spray  or  swabbing 
with  Dobell's  or  Seder's  solution  hurries  the  cure  of  the 
disease 

PERITONSILLAR  ABSCESS. 

Synonyms  :  ( )ther  names  for  this  condition  are  phlegmonous, 
or  suppurative  tonsillitis  and  quinsy. 

Peritonsillar  abscess — etiology  :  The  direct  cause  is  infection 
of  the  connective  tissue  in  the  neighborhood  of  the  tonsil  by 
pus-producing  micro-organisms.  Predisposing  causes  are 
chronic  pharyngitis  and  hypertrophy  of  the  tonsils.  Certain 
individuals  have  a  marked  tendency  to  recurrent  attacks. 


86  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Pathology :  The  peritonsillar  connective  tissue,  and  not  the 
tonsil  itself,  is  the  part  in  which  the  lesion  is  located.  The 
abscess  is  unilateral  and  tends  to  point  through  the  anterior 
faucial  pillar  a  little  above  the  tonsil. 

Peritonsillar  abscess — symptoms :  The  disease  begins 
abruptly  with  somewhat  the  same  general  symptoms  as  follic- 
ular tonsillitis,  but  less  marked :  chilly  sensations,  fever, 
headache,  and  backache.  The  local  symptoms  are  more  pro- 
nounced, the  pain  in  the  throat  being  very  severe  and  shoot- 
ing into  the  ear.  Swallowing  and  moving  the  jaw  for  any 
purpose  make  the  pain  intense.  After  a  few  days  the  patient 
presents  quite  a  characteristic  appearance  with  immovable 
jaw,  slightly  opened  mouth,  thick  nasal  voice,  and  mucus  and 
saliva  drooling  from  the  lips.  The  neck  on  the  same  side  is 
quite  swollen. 

On  inspection  the  region  around  one  tonsil  is  badly  swollen 
and  oedematous.  The  uvula  is  swollen  and  pushed  to  the 
opposite  side.  It  seems  impossible  for  the  patient  to  open 
the  mouth  wide.  On  palpation  a  soft  fluctuating  swelling  is 
detected  just  above  and  in  front  of  the  tonsil. 

Prognosis :  Recovery  is  the  rule.  Death  may  occur  from 
rupture  of  the  abscess  into  the  larynx. 

Peritonsillar  abscess — treatment :  The  disease  may  possibly 
be  aborted  in  the  first  stages  by  heroic  dosing  with  sodium 
salicylate  after  the  use  of  a  saline  purge,  and  local  appli- 
cations of  strong  solutions  of  nitrate  of  silver.  There  is, 
however,  always  the  question  of  doubt  as  to  the  diagnosis  in 
the  beginning. 

If  we  decide  that  the  disease  is  going  on  to  the  formation 
of  pus,  the  process  may  be  hastened  by  hot  applications  to 
the  neck  and  the  frequent  inhalation  of  steam  by  the  mouth. 
These  applications  likewise  give  some  relief  to  the  pain.  As 
soon  as  pus  shows  its  presence  a  free  incision  should  be  made 
with  a  pointed  bistoury  in  the  fluctuating  point.  This  will 
usually  be  above  the  tonsil  at  about  the  juncture  of  the  hard 
and  soft  palates.  If  pus  is  well  localized,  the  relief  is  imme- 
diate. After-treatment  consists  in  washing  out  the  sac  and 
keeping  the  exit  open. 


CHRONIC  TONSILLITIS.  87 


CHRONIC  TONSILLITIS. 


Hypertrophy  of  the  tonsils  is  the  better  name  for  this  con- 
dition, as  the  essential  lesion  is  a  marked  increase  in  the  size 
of  the  glands. 

Etiology :  This  condition  is  part  of  the  same  so-called 
"lymphatism"  as  is  seen  in  adenoids,  a  constitutional  ten- 
dency to  hypertrophy  of  lymphatic  structures.  They  begin 
to  enlarge  very  early  in  life,  and  are  at  times  even  congenital. 
Frequent  acute  attacks  and  climatic  conditions  probably  pre- 
dispose. 

Pathology:  There  is  a  hyperplasia  of  both  the  connective- 
tissue  stroma  and  of  the  lymphoid  tissue  of  the  tonsils. 
Either  may  predominate,  producing  a  harder  or  softer  variety 
of  hypertrophy. 

Chronic  tonsillitis — symptoms :  Hypertrophied  tonsils  so 
frequently  coexist  with  adenoids  of  the  naso-pharynx  that 
the  symptoms  of  the  two  conditions  are  blended.  They 
cause  mechanical  obstruction  to  nasal  breathing,  with  snoring 
and  nasal  voice,  and  to  swallowing.  They  predispose  to 
attacks  of  acute  tonsillitis.  Deafness,  mouth-breathing  and 
its  concomitants — change  in  the  shape  of  the  maxillary  bones 
— follow.  The  blood  being  imperfectly  aerated,  these  chil- 
dren suffer  from  disturbed  sleep  and  night-terrors.  Both  the 
tonsils  are  affected,  and  remain  in  the  same  condition  up  to 
puberty,  when  they  may  shrink  some,  especially  if  they  are 
of  the  soft  variety.  The  enlargement  of  the  throat  at  this 
times  also  gives  them  more  room,  and  the  local  symptoms 
after  this  are  less  troublesome. 

The  tonsils  appear  prominent,  and  project  toward  the 
median  line,  at  times  almost  touching  each  other.  Their  sur- 
faces are  full  of  deep  excavations,  the  natural  crypts. 

Chronic  tonsillitis — treatment :  Local  applications  and  drugs 
arc  of  no  value  in  these  cases.  The  only  satisfactory  treat- 
ment  is  their  surgical  removal. 

This  is  best  done  by  one  of  the  instruments  specially  con- 
structed  lor  this  purpose,  of  which  MaeKenzie's  is  the  least 
complicated.  The  tonsils  can  be  removed  quickly  with  very 
little  pain,  and  the  hemorrhage  afterward   is  trifling  in  ehil- 


88  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

dren.  It  is,  however,  always  well  to  have  some  means  for 
stopping  bleeding  at  hand,  as  a  few  rare  cases  are  reported 
where  such  means  was  needed.  Styptics  or  digital  compres- 
sion may  be  tried.  If  enough  of  the  tonsil  is  removed,  recur- 
rence is  rare. 

If  operation  cannot  be  done,  local  astringents  may  be  tried, 
and  syrup  of  the  iodide  of  iron  given  internally.  After  the 
operation  a  gray  appearance  is  frequently  seen  on  the  stump, 
which  may  arouse  suspicion  of  diphtheria,  but  is  only  the 
coating  of  the  cut  surface. 

ACUTE  OESOPHAGITIS. 

Etiology :  Inflammation  of  the  mucous  membrane  of  the 
oesophagus  is  most  often  caused  by  the  passage  of  some  hard 
substance,  as  metal  or  bone ;  or  some  hot  or  corroding  chemi- 
cal, as  too  hot  food,  or  acid,  or  lye. 

Symptoms  :  Burning  pain  in  the  oesophagus,  neck,  back, 
and  pericardium,  with  painful  swallowing,  intense  thirst, 
retching,  and  vomiting  are  the  regular  symptoms.  Ulcera- 
tions are  almost  always  formed,  and  in  three  to  six  months 
symptoms  of  oesophageal  stricture,  due  to  cicatrization  and 
cauterization  of  these  ulcers,  follow. 

Acute  oesophagitis — treatment :  This  depends  on  the  cause. 
If  &  foreign  body  is  lodged  in  the  gullet,  attempts  to  remove 
it  should  be  made.  If  a  corrosive  fluid  has  been  swallowed, 
the  proper  antidotes  should  be  given,  followed  by  oils  and 
demulcent  drinks.  Opium  is  necessary  to  relieve  the  pain. 
If  stricture  is  forming,  regular  passage  of  oesophageal  sounds 
should  be  practised.  If  stricture  has  formed,  the  treatment 
is  surgical. 

CONGENITAL  FISTULA  OF  THE  NECK. 

In  embryonic  life  the  openings  between  the  second  and 
third  branchial  clefts  may  fail  to  close,  leaving  a  small  or 
large  opening  in  the  neck  just  above  and  a  little  outside  of 
the  sterno-clavicular  joint.  These  openings  usually  com- 
municate with   the  oesophagus.     They  are  not  serious,  but 


SWALLOWING  FOREIGN  BODIES  89 

may  be  troublesome   from  being  occasionally  occluded,  the 
secretion    being    dammed    up  behind    and    forming  a   cystic 
tumor.      The  discharge  from  the  sinus  may  be  bothersome. 
Treatment :  This  is  entirely  surgical. 

RETROESOPHAGEAL  ABSCESS. 

Definition  :  This  condition,  as  its  name  implies,  is  a  collec- 
tion of  pus  behind  the  oesophagus  and  in  front  of  the  bodies 
of  the  lower  cervical  or  upper  dorsal  vertebrae,  lower  than  the 
retro-pharyngeal  abscess. 

Etiology :  There  are  three  forms  of  this  abscess  :  that  due 
to  simple  suppuration  of  the  lymph-glands  in  the  posterior 
mediastinum  ;  that  due  to  tubercular  inflammation  and  break- 
ing down  of  these  same  glands ;  and  that  due  to  caries  of  the 
body  of  one  or  more  of  the  dorsal  vertebras. 

Retro-oesophageal  abscess — symptoms  :  These  are  vague,  and 
a  diagnosis  is  very  difficult  to  make.  The  main  symptoms 
seem  to  be  dependent  on  irritation  of  one  or  the  other  of  the 
pneumogastric  nerves,  which  lie  next  to  the  oesophagus. 
Sudden  attacks  of  dyspnoea,  or  of  inhibition  of  the  heart's 
action,  are  the  commonest  reported  symptoms.  Dysphagia 
seems  not  to  be  marked. 

Prognosis  :  This  is  bad,  as.  diagnosis  is  next  to  impossible, 
and  hence  treatment  is  out  of  the  question.  If  the  abscess 
ruptures  spontaneously  into  the  oesophagus,  recovery  may 
follow. 

SWALLOWING  FOREIGN    BODIES. 

Children  are  frequently  brought  to  a  physician  with  the 
story  of  having  swallowed  a  foreign  body  of  some  kind,  as 
coins,  buttons,  jackstones,  tacks,  pins,  pieces  of  bone,  and 
various  other  objects.  Always  investigate  the  history  care- 
fully, to  be  sure  of  the  fact.  As  a  rule,  these  bodies  pass 
into  the  stomach  and  through  the  intestines,  and  are  dis- 
charged from  the  rectum  without  causing  any  disturbance. 

At  times  they  lodge  in  the  pharynx,  or  in  the  oesophagus, 
and  may  cause  unpleasant  symptoms  from  their  presence. 
These  symptoms  are  pain,  dysphagia,  retching,  and  cough. 
Some  blood-stained  mucus  may  be  brought  up. 


90  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

The  pharynx  should  be  carefully  inspected  and  palpated 
by  the  linger,  and  if  the  body  can  be  found  it  should  be  re- 
moved. 

If  it  is  lodged  in  the  oesophagus,  attempts  to  remove  it 
with  a  probang  or  to  push  it  down  with  a  sound  may  be  made. 
CEsophagotomy  may  be  necessary. 

If  the  foreign  body  has  passed  into  the  stomach,  do  not 
give  a  purge  or  emetic,  but  give  the  child  a  good  meal  of 
potatoes  or  bread,  to  form  a  protective  coating  for  the  body 
during  its  passage  through  the  intestines. 

DISEASES  OF  THE  STOMACH. 

ACUTE  GASTRIC  INDIGESTION. 

Definition  :  In  this  condition  the  stomach  is  unable,  through 
functional  causes  only,  to  perform  temporarily  its  digestive 
duties. 

Etiology :  The  main  causes  are  improper  food,  the  too  early 
use  of  solid  food  in  infants,  sudden  weaning,  and  overload- 
ing the  stomach.  In  other  words,  the  use  of  food  of  an  indi- 
gestible character  for  a  child  of  the  age  to  whom  it  is  given. 
The  stomach  may  itself  be  at  fault  in  certain  cases  through 
general  causes,  as  fatigue,  or  general  depression,  or  excessive 
heat. 

Pathology :  Two  conditions  may  be  present,  a  decrease  in 
the  gastric  juice  and  a  lack  of  muscular  peristalsis.  Inflam- 
mation is  absent. 

Acute  gastric  indigestion — symptoms  :  The  food  remains  in 
the  stomach  longer  than  normal,  and  excites  pain  in  the  epi- 
gastrium, nausea,  vomiting,  and  a  marked  malaise.  The  ap- 
petite is  lost,  the  patient  has  attacks  of  faintness,  and  a  good 
deal  of  headache.  After  the  stomach  is  completely  emptied 
the  symptoms,  as  a  rule,  rapidly  disappear.  In  some  cases 
there  is  fever  up  to  102°  F.,  and  symptoms  of  toxaemia,  dul- 
ness  and  stupor ;  or  the  opposite,  restlessness  and  even  con- 
vulsions, may  develop.  The  pulse  becomes  weak,  and  pros- 
tration is  pronounced.  There  is  distention  of  the  abdomen, 
and  later  usually  diarrhoea.     The  shortness  of  the  attack  and 


ACUTE  GASTRITIS.  91 

the  termination  of  the  symptoms  after  thorough  vomiting, 
differentiate  the  condition  from  gastritis. 

Acute  gastric  indigestion — treatment :  If  the  stomach  has 
not  been  thoroughly  emptied,  it  should  be  cleaned  out  com- 
pletely, and  this  is  best  done  by  means  of  the  stomach-tube. 
If  unable  to  use  lavage,  large  quantities  of  lukewarm  water 
may  be  given,  or  an  emetic,  as  ipecac.  If  vomiting  is  persis- 
tent, cracked  ice,  or  lime-water,  or  soda-water,  given  in  small 
quantities,  will  usually  check  it.  Fractional  doses  of  calo- 
mel, grain  ^ ,  every  hour  for  ten  doses,  will  tend  to  quiet  the 
stomach  and  to  remove  by  the  bowels  any  indigestible  matter 
left  behind. 

After  cleaning  the  stomach  stop  completely  the  food  which 
has  been  used,  and,  if  possible,  stop  all  food  for  some  hours, 
giving  the  stomach  absolute  rest.  If  the  demand  for  food  is 
marked,  egg-water  mixture  or  whey  given  in  small  quantities 
is  the  best  form  of  food  for  a  day  or  two,  when  the  original 
food  may  be  gradually  resumed.  During  the  continuance  of 
the  pain  hot  applications  to  the  epigastrium  are  very  soothing. 

ACUTE  GASTRITIS. 

Definition :  Here  there  is  an  inflammatory  change  in  the 
mucous  membrane  lining  the  stomach. 

Etiology :  The  causes  are  the  same  as  of  gastric  indiges- 
tion :  indigestible  foods  and  the  swallowing  of  irritants,  drugs, 
and  chemicals. 

Pathology  :  The  gastric  mucous  membrane  is  in  a  condition 
of  catarrhal  inflammation,  with  congestion  and  swelling,  and 
exudation  of  cells  into  the  stroma,  accompanied  by  marked 
increase  of  the  mucous  secretion  of  the  membrane,  and  des- 
quamation of  the  epithelium.  The  changes  are  fairly  well 
distributed  throughout  the  stomach.  The  organ  is  full  of 
undigested  food  and  mucus.  There  may  be  slight  blood  ex- 
travasations. In  rare  cases  a  false  membrane  may  form  on 
the  mucous  membrane.  In  cases  due  to  swallowing  of  chemi- 
cals ulcers  may  be  found  scattered  irregularly  around  the 
organ,  but  usually  on  the  greater  curvature. 

Acute   gastritis — symptoms:    The   disease    begins,  as    does 


92  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

gastric  indigestion,  with  pain  in  the  epigastrium,  nausea,  vom- 
iting, headache,  faintness,  loss  of  appetite,  coated  tongue, 
prostration,  and  fever.  But  these  symptoms,  instead  of  dis- 
appearing after  the  stomach  has  been  emptied,  persist,  and 
vomiting  of  mucus  continues  even  after  all  the  food  has  been 
ejected.  The  temperature  continues  somewhat  raised  and 
thirst  is  very  prominent.  The  pulse  and  respiration  are  like- 
wise quickened.  Intestinal  symptoms  very  commonly  coexist 
or  follow.     The  attacks  last  somewhat  less  than  a  week. 

Prognosis:  Simple  acute  gastritis  in  a  previously  strong 
child  is  usually  recovered  from.  In  delicate  children,  or  if 
improperly  managed,  serious  results  may  follow,  or  the  disease 
may  be  the  forerunner  of  a  severe  gastro-enteritis.  We  must 
never  forget  that  the  attack  may  be  the  beginning  of  one  of 
the  infectious  diseases,  more  particularly  scarlatina. 

Acute  gastritis — treatment :  The  stomach  must  be  com- 
pletely emptied  of  any  irritants,  and  this  is  best  done  by 
lavage.  Warm  water  or  ipecac  may  be  used  as  emetics  if 
lavage  is  unadvisable.  Afterward  give  calomel,  grain  -^ 
every  hour  for  ten  doses,  to  remove  any  remaining  portion 
of  the  irritant.  Cracked  ice,  or  bicarbonate  of  sodium,  or 
bismuth  will  usually  check  the  vomiting  if  it  becomes  per- 
sistent.    Hot  applications  to  the  epigastrium  are  helpful. 

The  dietetic  treatment  is  very  important,  with  complete 
stoppage  of  all  food  for  as  long  as  possible,  and  when  begun 
again  using  small  amounts  of  something  very  bland  and  easy 
to  digest,  as  egg- water  or  whey.  Gradual  return  to  regular 
food  should  be  made  after  the  symptoms  have  subsided. 

If  the  gastritis  is  due  to  swallowing  some  chemical,  the 
proper  antidote  should  be  given,  and  followed  by  demulcents. 
Opium  may  be  needed  for  the  pain. 

GASTRO-DUODENITIS. 

Definition  :  This  is  an  acute  inflammation  of  the  stomach 
and  duodenum,  with  an  extension  of  the  inflammatory  proc- 
ess into  the  common  bile-duct  and  resultant  obstructive 
jaundice.     Another  name  for  it  is  catarrhal  jaundice. 

Etiology :  The  causes  are  not  well   understood,  but  prob- 


CHRONIC  GASTRITIS.  93 

ably  they  are  somewhat  similar  to  those  of  acute  gastritis — the 
use  of  improper  food.     There  may  be  an  infectious  element. 

Pathology  :  T  here  is  inflammation,  with  congestion,  swelling, 
increased  secretion,  and  desquamation  of  the  epithelium 
from  the  mucous  membrane  of  the  pyloric  end  of  the 
stomach,  of  the  duodenum,  and  of  the  common  bile-duct. 
The  swollen  mucous  membrane  of  the  duct  causes  its  occlu- 
sion and  subsequent  obstruction  to  the  blow  of  bile. 

Castro-duodenitis — symptoms  :  The  attack  begins  rather 
suddenly,  with  pain  in  the  neighborhood  of  the  duodenum, 
nausea,  vomiting,  constipation,  fever,  rapid  pulse,  and  general 
malaise. 

After  a  few  days  the  typical  symptom  of  the  disease, 
jaundice,  makes  its  appearance  first  in  the  conjunctivas,  then 
in  the  skin.  The  urine  will  contain  bile  and  the  faeces  be 
clay  colored.  The  appetite  is  lost  and  the  tongue  thickly 
coated.  After  the  jaundice  has  been  present  a  short  time 
the  skin  becomes  itchy,  and  the  pulse  may  be  slow.  The 
patient  is  languid,  and  good  for  nothing.  The  liver  may 
show  slight  enlargement  and  some  tenderness. 

Prognosis  :  The  disease  lasts  about  two  weeks,  and  recovery 
is  the  regular  outcome. 

In  the  treatment  of  gastro-duodenitis  the  diet  should  be 
restricted  to  milk  or  scraped  meat,  the  fats  and  starches  being 
specially  excluded.  Water  should  be  given  freely,  and  the 
bowels  kept  loose  by  fractional  doses  of  calomel  given  on  alter- 
nate days,  and  followed  by  some  saline  laxative,  as  phosphate 
of  sodium.  Hot  applications  to  the  epigastrium  will  relieve 
the  pain.  Alkalies  or  lavage  may  be  needed  to  stop  the 
vomiting  in  the  early  stages. 

CHRONIC   GASTRITIS. 

Definition  :  This:  is  a  chronic  inflammatory  change  in  the 
gastric  mucous  membrane,  and  a  consequent  interference, 
more  or  less   marked,  with  the  functions  of  the  stomach. 

Etiology  :  The  causes  are  the  same  as  those  producing  acute 
gastritis,  only  being  prolonged  in  their  action.  The  use  of 
improper,   badly   prepared,    or    indigestible   food  ;    improper 


94  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

quantities  at  a  feeding;  irregularity  in  feeding;  rapid  eating 
or  imperfect  mastication,  if  continued  long  enough,  will  pro- 
duce this  condition.  These  causes  apply  equally  to  infants 
as  to  children  on  solid  food.     Bad  teeth  are  a  potent  cause. 

Frequent  attacks  of  acute  gastritis  predispose  to  the 
chronic  form.  The  presence  of  anaemia,  rachitis,  tubercu- 
losis, syphilis,  or  malnutrition  is  also  a  predisposing  factor. 
Chronic  heart,  liver,  or  kidney  diseases,  by  producing  venous 
engorgement,  likewise  are  predisposing  agents. 

Pathology  :  The  lesions  are  in  the  mucous  membrane,  con- 
sisting of  degeneration  of  the  epithelium  of  the  gastric 
tubules  and  increased  production  of  mucus.  If  the  process 
advances  further,  there  is  round-cell  infiltration  with  produc- 
tion of  new  connective  tissue,  and  consequent  destruction  of 
the  glandular  structure.  In  old  cases  the  stomach  becomes 
dilated  and  the  mucous  membrane  is  covered  with  a  large 
quantity  of  sticky  mucus. 

The  symptoms  of  chronic  gastritis  are  those  of  impaired 
digestion  and  failing  nutrition.  The  appetite  may  be  lessened 
or  increased,  belching  of  wind  and  nausea  are  regularly 
present,  and  vomiting  occurs  more  or  less  frequently.  The 
vomitus  consists  not  only  of  undigested  food,  but  also  of 
large  quantities  of  mucus.  The  younger  the  child  the  more 
marked  is  the  vomiting.  There  are  pain,  uneasy  sensa- 
tions, or  a  feeling  of  fulness  in  the  region  of  the  stomach. 
Headache,  irritability,  and  disturbed  sleep  may  follow.  The 
bowels  are  apt  to  be  constipated,  but  there  may  be  diarrhoea 
from  the  passage  of  undigested  food  into  the  intestines.  This 
is  most  common  in  infants.  The  tongue  is  coated,  the  breath 
smells  badly,  and  there  is  a  bad  taste  in  the  mouth  on 
awaking. 

Signs  of  failure  of  nutrition  follow,  either  a  lack  of  gain 
or  a  loss  in  weight.  The  child  grows  anaemic  and  feeble, 
and  loses  its  energy. 

Prognosis :  In  infants  the  disease  is  serious  by  interfering 
with  the  normal  growth  of  the  child  and  in  predisposing  to 
attacks  of  intestinal  disturbance.  In  older  children,  if  the 
cause  is  removed  and  proper  treatment  instituted,  many  re- 
cover ;  but  lacking  these  the  disease  tends  to  go  on  and  grow 


DILATATION  OF  THE  STOMACH.  95 

worse  as  time  advances  in  the  presence  of  a  continuously 
acting  cause.  Although  these  older  children  seldom  die  from 
the  disease  or  its  complications,  they  become  the  confirmed 
dyspeptics  of  adult  life. 

Chronic  gastritis — treatment :  The  dietetic  care  is  most  im- 
portant, and  all  the  causative  factors  of  this  class  should  be 
investigated  and  errors  corrected.  The  right  food,  in  proper 
quantities,  at  regular  intervals,  correctly  prepared,  and  thor- 
oughly masticated  should  be  taken.  If  the  teeth  are  faulty, 
they  should  be  attended  to.  A  hygienic  life  should  be  pre- 
scribed, with  proper  exercise,  sleep,  and  bathing. 

Daily  ivashing  of  the  stomach  with  plain  boiled  water,  or 
with  warm  water  to  which  some  alkali  has  been  added,  is  the 
very  best  local  treatment.  It  removes  the  mucus  and  undi- 
gested food,  and  stimulates  the  production  of  gastric  juice 
and  the  muscular  tone  of  the  stomach. 

The  drugs  that  are  of  value  are  either  sodium  bicarbonate, 
or  hydrochloric  acid,  or  mix  vomica,  or  pepsin,  alone  or  in 
various  combinations ;  but  too  much  reliance  must  not  be 
placed  on  any  one  of  them. 

DILATATION  OF  THE  STOMACH. 

Definition :  A  more  or  less  enlarged  stomach  in  infants  is  a 
fairly  frequent  condition,  especially  when  fed  artificially. 

Etiology  :  The  most  common  cause  is  the  almost  universal 
habit  of  overfeeding  artificially  fed  infants.  The  other  causes 
which  predispose  are  rickets  and  chronic  gastritis. 

Pathology:  The  dilatation  is  usually  symmetrical  and  may 
become  enormous.  In  rare  instances  there  may  be  a  congeni- 
tal stenosis  of  the  pylorus  underlying  the  condition. 

Dilatation  of  the  stomach — symptoms :  The  main  symptoms 
are  du  ■  to  the  accompanying  chronic  indigestion.  Vomiting 
attends  the  cases  due  t<>  pyloric  blockage. 

The  diagnosis  is  made  by  physical  examination,  proving 
the  presence  of  a  dilated  stomach  after  it  lias  been  filled  with 
gas  or  water. 

Prognosis  :  This  is  good  except  in  cases  of  pyloric  obstruc- 
tion. 


96  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Treatment :  Remove  the  cause  by  regulating  the  meals. 
Improve  the  tone  of  the  stomach  by  lavage  and  the  use  of 
nux  vomica.     If  rickets  is  present,  treat  this. 

ULCER  OF  THE  STOMACH. 

Gastric  ulcer  is  found  only  rarely  in  children;  but  a  few 
cases  are  reported  from  time  to  time. 

Etiology :  Ulcers  may  be  due  to  follicular  gastritis  or  tubercu- 
losis, or  belong  to  the  same  category  as  in  adults — of  unknown 
cause. 

Pathology :  The  ulcer  may  be  single  or  multiple,  and  usu- 
ally involves  only  the  mucous  membrane.  Its  position  on 
the  stomach-wall  is  uncertain. 

Symptoms:  Gastric  pain  increased  by  the  ingestion  of  food, 
nausea,  vomiting,  and  hrematemesis  are  the  characteristic 
symptoms.  Usually  some  gastritis  is  present,  adding  its 
symptoms. 

Prognosis  :  This  is  rather  unfavorable. 

Ulcer  of  the  stomach — treatment :  If  diagnosis  is  made,  the 
child  should  be  kept  in  bed  and  the  stomach  given  absolute 
rest  by  withholding  all  food  by  mouth,  the  child  being  nour- 
ished by  enemata  of  predigested  food.  The  drugs  used  are 
silver  nitrate,  bismuth,  and  opium,  but  none  is  of  much 
value. 

DISEASES  OF  THE  INTESTINES. 

ACUTE  IRRITATIVE  DIARRHOZA. 

Synonyms :  Other  names  for  this  condition  are  simple  diar- 
rhoea, mechanical  diarrhoea,  and  nervous  diarrhoea.  It  is 
meant  to  include  cases  without  anatomical  changes  in  the  in- 
testines, and  without  involvement  of,  or  influence  from,  the 
stomach.  The  absence  of  a  bacterial  cause  is  shown  by  ref- 
erence to  the  etiology. 

Etiology :  The  exciting  causes  are  various,  but  the  same 
underlying  predispositions  exist  as  in  all  diarrhoeas.  These 
are  age,  the  first  two  years  of  life,  unhygienic  surroundings, 
malnutrition  from  any  cause,  and  hot  weather. 


ACUTE  IRRITATIVE  DIARRHCEA.  97 

The  active  causes  are  excessive  feeding  ;  the  use  of  foods  un- 
suitable to  the  age  of  the  child,  and  which  consequently  act 
virtually  as  foreign  bodies,  such  as  green  corn,  cabbage,  rad- 
ishes, partially  cooked  starches,  fruits,  and  such  stuff;  the 
swallowing  of  foreign  bodies ;  ordinary  drugs  in  susceptible 
infants  used  as  laxatives;  reflex  nervous  influences,  as  exhaus- 
tion, chilling  the  surface,  excessive  heat,  fright,  and  rarely 
dentition ;  eliminative  efforts  of  nature  to  excrete  toxic  sub- 
stances from  the  body  by  the  intestines,  of  which  urcemic 
diarrhoea  is  the  best  example. 

Acute  irritative  diarrhoea — pathology  :  There  is  neither  in- 
testinal fermentation  nor  intestinal  inflammation.  Increased 
peristalsis  seems  at  the  bottom  of  this  form  of  diarrhoea, 
caused  by  local  direct  irritation  or  reflexly.  With  it  some 
hyperemia  of  the  intestinal  mucous  membrane  and  an  in- 
creased secretion  from  its  glands  are  present.  If  allowed  to 
progress,  an  intestinal  inflammation  may  supersede,  or  bacte- 
rial invasion  and  fermentation  of  the  intestinal  contents  may 
follow. 

Symptoms  :  These  usually  begin  suddenly  with  abdominal 
pain  and  diarrhoea.  The  first  stools  are  soft  faeces  ;  later  they 
become  thin  and  watery,  averaging  six  to  ten  a  day.  The 
child  is  restless,  somewhat  weak  and  exhausted,  and  has  a 
clammy  perspiration.  There  is  no  vomiting  and  no  fever. 
The  stools  are  yellow  or  brown.  Their  odor  is  not  bad.  If 
due  to  irritating  foreign  bodies,  these  will  appear  in  the 
stools.  The  abdomen  is  swollen  and  the  increased  peristaltic 
movements  of  the  intestines  are  evident  to  the  sight  and  touch. 

Prognosis  :  These  cases  regularly  recover  in  a  few  days, 
nature  removing  the  irritant  from  the  bowels.  Under  un- 
favorable conditions  the  attack  may  lead  to  one  of  the  more 
serious  forms  of  diarrhoea. 

Acute  irritative  diarrhoea — treatment:  Follow  nature's  lead 
and  first  give  a  cathartic,  of  which  castor  oil  is  the  best. 
Calomel  in  divided  doses  may  be  used,  bu1  is  slower.  This 
removes  the  irritanl  completely  from  the  bowel.  Four  to  six 
hours  later  give  the  proper  dose  of  opium  ami  repeal  as  occa- 
sion requires.  This  had  best  be  given  uncombined,  and  live 
t<>  ten  drop-  of  paregoric  to  a  child  a  year  <>M  are  the  right 
7—1).  C. 


98  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

sized  dose.  Food  should  be  withheld  as  far  as  possible  for  a 
day,  and  when  begun  should  be  bland  and  given  in  small 
quantities. 

ACUTE  FERMENTAL  DIARRHCEA. 

Synonyms :  This  is  the  common  diarrhoea  of  summer  that 
is  the  cause  of  the  high  infantile  mortality  at  that  time.  The 
names  given  it  are  almost  as  many  as  the  authors  writing  of 
it.  They  are  summer  diarrhoea,  acute  dyspeptic  diarrhoea, 
gastro-intestinal  catarrh,  infectious  diarrhoea,  gastro-enteric 
infection,  and,  very  erroneously,  cholera  infantum. 

The  name  chosen  expresses  the  condition  as  well  as  any — 
i.  e.,  that  of  fermentation  or  decomposition  of  the  intestinal 
contents  by  bacterial  invasion. 

Etiology :  The  causes  are  summer  heat,  artificial  feeding, 
bad  habits  of  feeding,  overfeeding,  improper  food,  impure 
milk,  bad  hygienic  surroundings,  and  residence  in  the  city. 
The  excessive  heat  of  the  summer  combined  with  high  humid- 
ity in  the  atmosphere  seems  the  main  predisposing  factor. 
During  long  terms  of  hot  weather  this  form  of  diarrhoea  seems 
to  sweep  in  epidemics  through  the  infants  in   large   cities. 

Behind  all  these  causes,  but  acting  as  the  direct  ex- 
citants of  the  disease,  are  undoubtedly  various  forms  of  germ 
life,  which  are  introduced  with  the  food  into  the  child's  diges- 
tive tract,  and  for  which  the  milk  or  other  food  taken  acts  as 
a  culture-medium.  Attempts  are  being  made  to  isolate  and 
separate  the  forms  of  micro-organisms  responsible  for  these 
conditions,  but  as  yet  no  very  definite  results  have  been 
reached.  The  probabilities  are  that  there  are  many  different 
varieties  of  germ  life  in  each  case,  each  contributing  its  share 
to  the  disturbance,  and  that  no  one  form  of  germ  is  alone  the 
cause  of  the  disease. 

In  a  child  previously  unhealthy  from  any  cause  these  fac- 
tors, germs,  bad  feeding,  and  heed,  are  far  more  likely  to  pro- 
duce this  disease  than  in  a  perfectly  well  infant.  Further, 
the  great  majority  of  these  cases  are  seen  in  artificially  fed 
children,  breast-fed  babies  being  rarely  attacked,  thus  show- 
ing the  necessity  for  the  action  of  all  three  factors  at  once. 


ACUTE  FERMENT AL   DIARRHCEA.  99 

Pathology :  Essentially  this  disease  is  non-inflammatory, 
but  is  a  putrefaction  of  the  food-contents  of  the  intestine  due 
to  the  presence  of  bacteria  of  one  kind  or  another.  In  a 
healthy  child  and  with  a  short  attack  of  the  disease,  virtu- 
ally no  anatomical  changes  take  place.  If  the  child  is  non- 
resistent  and  the  attack  severe  and  lasting,  early  changes  in 
the  intestines  are  desquamation  of  the  epithelium  of  the  mu- 
cous membrane,  going  on  if  further  continued  to  the  changes 
seen  in  the  inflammatory  diarrhoeas.  The  gross  appearances 
in  the  intestinal  mucous  membrane  are  almost  none. 

Acute  fermental  diarrhoea — symptoms :  The  disease  may 
begin  gradually  with  slight  looseness  of  the  bowels,  associated 
with  symptoms  of  general  malaise,  some  fever,  restlessness, 
and  fretfulness  ;  or  more  acutely  with  high  fever,  frequent 
vomiting,  and  marked  diarrhoea. 

In  the  gradual  form  the  diarrhoea  is  the  main  symptom. 
The  stools  are  fairly  frequent,  eight  to  ten  a  day,  yellow 
or  more  frequently  green  and  thin,  and  contain  masses  of 
undigested  food,  curdled  proteids,  and  fat.  They  may  con- 
tain mucus  and  at  times  a  little  blood.  At  first  the  odor  is 
sour  only,  but  later  becomes  offensive.  Anorexia  is  usually 
present.  The  tongue  is  coated  white.  Thrush  frequently 
develops  in  the  mouth.  The  child  soon  becomes  pale,  the 
muscles  grow  soft  and  flabby,  and  he  loses  flesh  from  week 
to  week. 

The  disease  terminates  under  favorable  circumstances  by  a 
gradual  change  to  the  normal  in  the  stools,  and  by  a  gain  in 
strength  and  flesh.  Under  unfavorable  conditions  the  cases 
go  on  to  a  chronic  intestinal  fermentation  which  remains  till 
the  cold  weather  comes ;  or  it  may  develop  suddenly,  under 
tin'  influence  of  very  hot  weather,  into  a  case  of  genuine 
cholera  infantum  ;  or  it  may  be  the  starting-point  of  an  entero- 
colitis. 

"\\  hen  beginning  acutely  the  symptoms  usually  continue 
acute.  The  fever  keeps  at  about  102°  F.  ;  there  are  marked 
restlessness,  irritability,  and  often  convulsions  ;  or,  on  the 
contrary,  stupor  and  great  prostration.  The  vomiting  re- 
mains frequent,  at  first  curdled  milk  being  ejected,  and  later 
mucus,  serum,  and   bile   may  follow.      Any  food   or  drink   is 


100  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

immediately  returned.  The  appetite  is  gone,  but  thirst  is 
marked  and  fluid  food  is  eagerly  taken  to  quench  it. 

The  bowels  move  frequently,  in  the  beginning  the  stools 
being  faecal,  and  later  being  thin,  yellowish  or  greenish,  with 
a  great  deal  of  gas  and  an  offensive  odor.  There  may  be  a 
dozen  or  more  stools  per  day.  The  diarrhoea  is  characterized 
especially  by  the  large  amount  of  gas  expelled  and  the  very 
putrid  odor  of  the  stools.  The  abdomen  is  distended  and 
tender,  and  the  infant  evidently  suffers  from  intense  colicky 
pains.  After  three  or  four  days  of  these  symptoms  the  tem- 
perature falls,  the  stools  become  less  frequent,  the  vomiting 
stops,  and  under  proper  management  the  child  will  go  on  to 
complete  recovery. 

Under  less  favorable  circumstances — that  is,  a  feeble  child 
and  continued  bad  feeding — an  inflammatory  entero-colitis 
supervenes.  Others  terminate  in  death  during  the  acuteness 
of  the  attack. 

Diagnosis  :  This  form  of  diarrhoea  must  be  differentiated 
from  cholera  infantum,  entero-colitis,  and  the  beginning  of 
several  of  the  acute  diseases,  such  as  tonsillitis,  scarlet  fever, 
pneumonia,  and  malaria.  The  diagnosis  may  be  difficult  at 
first,  but  a  few  days  of  careful  observation  will  usually  clear 
up  the  case. 

Acute  fermental  diarrhoea — prognosis :  In  a  previously  healthy 
child,  and  with  proper  management,  which  means  feeding, 
these  cases  usually  recover.  In  institutions;  in  children  suffer- 
ing from  marasmus,  rickets,  and  other  nutritional  disorders ; 
among  unhygienic  surroundings ;  with  previous  chronic  indi- 
gestion from  wrong  feeding ;  and  in  very  hot  weather,  the 
mortality  from  this  form  of  diarrhoea  is  high. 

Prophylaxis :  This  is  of  great  importance,  as  the  majority 
of  these  cases  of  acute  fermental  diarrhoea  may  be  prevented 
by  proper  attention  to  a  few  essentials.  During  the  hot  sum- 
mer such  babies,  as  can,  should  be  sent  from  the  cities  to  the 
country,  and  those  in  a  hot  country  to  a  cooler  climate.  If 
this  is  impossible,  much  may  be  done  by  keeping  the  child  in 
the  air  and  out  of  doors  as  much  as  possible  both  day  and 
night.  Frequent  cool  bathing  both  promotes  cleanliness  and 
assists  in  keeping  the  temperature  of  the  surface  lower.    The 


ACUTE  FERMENTAL   DIARRHCEA.  101 

diapers  must  be  kept  scrupulously  clean,  especially  where  in- 
fants are  congregated.  In  any  case  of  diarrhoea  the  diapers 
particularly  should  be  disinfected. 

Feeding  should  be  carefully  regulated.  Encourage  breast- 
feeding in  every  way  possible  during  the  hot  mouths,  and 
postpone  weaning  till  cool  weather  begins.  If  artificial 
feeding  is  necessary,  this  should  be  thoroughly  regulated  as 
to  quality,  quantity,  and  intervals.  During  hot  weather 
special  attention  must  be  paid  to  the  purity  of  the  milk,  and 
unless  this  can  be  assured  some  form  of  sterilization  should 
be  adopted.  Foods  unsuited  to  a  child's  digestion  should 
be  absolutely  interdicted.  Excessive  feeding  particularly 
should  be  avoided.  Little  and  seemingly  unimportant 
gastric  or  intestinal  derangements  should  be  promptly 
corrected,  as  these  are  often  the  beginnings  of  more  serious 
disease. 

Acute  fermental  diarrhoea — treatment :  First  and  most  im- 
portant is  attention  to  the  food.  In  the  rare  cases  occurring 
in  breast-fed  infants  all  food  should  be  withheld  for  a  short 
time,  particularly  until  the  tendency  to  vomiting  is  passed. 
Small  quantities  of  water  may  be  given  instead  to  quench  the 
thirst.  As  the  breast  is  resumed,  the  quantity  allowed  at  a 
nursing  should  be  small  and  the  return  to  full  feeding  gradual. 

In  artificially  fed  children,  among  whom  the  vast  majority 
of  these  cases  occur,  all  milk  food  should  be  temporarily  pro- 
hibited. As  food  during  this  abstinence  from  milk  albumin- 
water  is  usually  the  best.  Broths,  rice-  or  barley-water,  or 
one  of  the  infant  foods  free  from  starch,  made  with  water 
only,  may  be  tried.  The  reason  for  the  prohibition  of  milk 
during  the  acuteness  of  the  attack  is  that  this  forms  the  best 
culture-medium  for  the  germs  whose  action  is  causing  the 
disease  By  depriving  them  of  their  food  we  starve  them 
out. 

After  the  attack  is  ended  we  must  return  to  a  milk  food 
very  slowly,  at  first  using  a  very  dilute  form,  and  gradually 
increasing  the  proportions  of  the  solid  ingredients  to  the 
proper  limit  for  the  child.  Small  quantities  at  a  feeding 
should  also  be  adhered  to.  In  some  of  these  eases,  especially 
the  very  young,  a  wet-nurse   must    be  secured   for  a   time. 


10'2  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

Milk  given  after  such  an  attack  is  over  should  always  be 
carefully  sterilized.  In  a  few  cases  peptonized  milk  is  useful 
for  a  time  until  the  stomach  regains  its  tone. 

In  older  children  on  solid  food  this  must  be  stopped,  and 
only  easily  digested  fluids  used  until  the  attack  is  over,  and 
then  the  return  to  the  regular  diet  should  be  gradual. 

Medicinally  our  first  purpose  is  to  clean  out  thoroughly 
from  both  stomach  and  intestine  all  the  fermenting  food-prod- 
ucts left  behind.  The  stomach  ordinarily  will  be  cleaned 
of  itself;  but  if  vomiting  is  persistent,  it  may  require  our 
special  attention.  In  these  cases  nothing  is  so  efficacious  as 
lavage.  For  an  infant  a  No.  16,  American  scale,  soft-rubber 
catheter,  attached  by  rubber  tubing  to  a  funnel,  is  the  best 
size.  It  is  easily  passed,  the  passage  being  facilitated  by 
wrapping  the  child,  arms  and  all,  in  a  blanket,  and  the  act 
of  washing  is  quickly  accomplished.  Warm,  boiled  water  is 
the  best  medium,  although  a  little  bicarbonate  of  sodium  may 
be  added.     One  washing  is  usually  sufficient. 

The  intestines  should  next  be  thoroughly  emptied  by  a  tea- 
spoonful  or  more  of  castor  oil.  This  is  undoubtedly  the  most 
efficient  of  the  drugs  of  its  class;  but  if  the  stomach  is  irri- 
table, it  may  be  omitted.  If  the  stomach-tube  has  been  used, 
before  removal  the  oil  maybe  given  through  this.  Fractional 
doses  of  calomel  (a  tenth  of  a  grain  every  half  hour  till  ten 
or  twelve  doses  are  taken)  have  the  advantage  of  ease  of 
administration,  do  not  irritate  the  stomach,  and  have  some 
slight  antifermentative  action  in  the  intestines.  It  is  not  so 
thorough  and  not  so  quick  as  castor  oil,  however.  After  the 
cathartic  has  acted,  a  thorough  irrigation  of  the  colon  with 
warm  saline  solution  through  a  long  rectal  tube  cleans  out 
the  last  remnants  of  decomposition.  This  may  be  repeated 
every  day  with  advantage  in  most  cases. 

After  the  whole  alimentary  canal  has  been  thus  thoroughly 
emptied  the  use  of  some  antiseptic  drug  given  regularly  is  in 
order.  These  drugs  are  many,  but  the  best  of  them  all  is  the 
old  subnitrate  of  bismuth,  as  it  may  be  given  in  large  doses 
without  fear  of  poisonous  effects.  It  is  best  given  in  doses 
of  ten  to  twenty  grains  every  three  or  four  hours.  Other 
drugs  of  this  class  are  salol,  salicylate  of  sodium,  salicylate  of 


CHOLERA    INFANTUM.  103 

bismuth,  subgallate  of  bismuth,  calomel,  bichloride  of  mer- 
cury, and  creosote. 

Iu  the  more  subacute  and  prolonged  cases  the  use  of  one 
of  the  mineral  acids  is  at  times  of  value. 

The  use  of  opium  in  these  cases  is  indicated  by  marked 
pain  and  evident  peristalsis.  It  should  always  be  given  by 
itself,  and  never  combined  with  other  drugs.  Never  use  it 
until  after  the  alimentary  canal  is  thoroughly  cleaned  out. 
Paregoric  may  be  used,  five  to  ten  drops ;  or  Dover's  powder, 
one-fourth  to  one-half  a  grain.  These  doses  may  be  repeated 
in  two  to  four  hours  as  needed. 

The  vegetable  astringents  are  often  used,  but  are  not  very 
reliable,  although  the  tannin  in  them  does  combine  with  the 
toxins  to  form  insoluble  compounds. 

Stimulants  may  be  necessary  in  the  cases  with  marked 
prostration.  Brandy,  or  whiskey,  or  champagne  may  be  used. 
Blackberry  brandy  answers  the  double  purpose  of  a  mild 
astringent  and  stimulant.  Hot  baths,  mustard  applications, 
etc.,  may  be  used  in  great  weakness. 

In  prolonged  or  convalescing  cases  there  seems  profit  at 
times  in  the  use  of  some  of  the  digestive  ferments. 

The  hygienic  care  of  these  children  is  likewise  important. 
The  child  should  be  given  fresh  air  in  abundance  ;  should  be 
kept  as  cool  as  possible  ;  should  be  frequently  bathed  in  cool 
water ;  its  clothing  should  be  thin,  and  special  attention 
should  be  paid  to  disinfection  of  the  diapers.  If  possible, 
these  children  should  be  sent  away  from  the  hot  cities  to  the 
country,  especially  when  the  disease  shows  any  tendency  to 
become  protracted. 

CHOLERA  INFANTUM. 

Definition:  This  disease  is  undoubtedly  a  specific  infection 
of  the  milk  \\>a\  as  tool  1  by  the  infant  affected.  It  is  also 
called  choleriform  diarrhoea,  and  the  name  has  been  used 
wrongly  as  a  generic  term  for  all  summer  diarrhoeas  of  in- 
fancy. This  name  should  be  restricted,  however,  to  the  less 
common  class  of  cases  differing  essentially  from  the  form  just 
described,  and  also  from  the  inflammatory  varieties. 


104  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Cholera  infantum — etiology  :  This  disease  practically  never 
occurs  in  an  entirely  breast-fed  baby.  It  never  occurs  except 
in  hot  weather.  Although  careful  researches  have  been  made 
to  find  a  specific  micro  organism  in  cholera  infantum,  as  yet 
no  such  germ  has  been  isolated.  Various  forms  of  bacteria, 
however,  have  been  found ;  but  as  yet  it  has  not  been  proved 
to  be  caused  by  one  special  variety.  The  cause  is  invariably 
in  the  milk,  and  there  may  be  enough  of  the  toxic  elements 
present  in  the  milk  as  taken  to  produce  the  symptoms  imme- 
diately on  absorption  ;  or  they  may  be  manufactured  from 
the  milk  by  the  bacteria  in  the  digestive  tract.  Each  case  is 
one  of  poisoning  by  toxins  generated  in  the  milk  by  growth 
of  bacteria  in  it. 

The  disease  is  frequently  grafted  on  a  case  of  irritative  or 
fermental  diarrhoea,  or  occurs  in  a  convalescent  from  some 
form  of  inflammatory  diarrhoea.  It  may  attack  a  previously 
healthy  child,  but  this  is  far  less  common  than  the  above. 

Cholera  infantum — pathology :  This  again  is  not  a  diarrhoea 
with  anatomical  changes  in  the  intestinal  mucous  membrane, 
but  is  purely  a  poisoning  of  the  system  by  the  swallowing,  or 
manufacture  in  the  digestive  tract,  of  chemical  toxins.  In 
fact,  the  symptoms  are  due  far  more  to  absorption  of  poison- 
ous toxins  into  the  blood  than  to  the  presence  of  the  germs 
in  the  stomach  and  intestines. 

Cholera  infantum — symptoms  :  In  a  previously  healthy  child, 
or  in  one  already  showing  some  mild  intestinal  disorder,  there 
is  a  quite  sudden  attack  of  violent  vomiting  and  purging. 
These  two  symptoms  are  the  most  characteristic  of  the  dis- 
ease, and  may  continue  uninterruptedly  throughout.  The 
vomiting  is  frequent,  and  follows  every  attempt  to  introduce 
food  or  drink  into  the  stomach.  At  first  curdled  milk  is 
ejected,  and  later  mucus  and  serum  and  bile.  The  stools  are 
frequent,  fifteen  to  twenty  a  day,  at  first  faecal,  of  yellow, 
brown,  or  green  color,  and  later  losing  all  color,  and  consist- 
ing simply  of  large  quantities  of  serous  fluid.  These  are  the 
typical  stools  of  the  disease.  They  are  acid  in  the  beginning, 
but  when  they  become  serous  are  alkaline.  They  are  usually 
without  typical  odor,  but  in  some  cases  may  have  the  putrid 
smell  of  those  in  fermental  diarrhoea.     Under  the  microscope 


CHOLERA   INFANTUM.  105 

they  show  epithelial  and  round  cells  and  large  numbers  of 
bacteria. 

The  child  loses  flesh  and  color  very  rapidly  ;  the  eyes  sink 
in  their  sockets,  a  marked  pallor  develops  in  the  skin,  and  the 
flesh  seems  to  disappear  almost  under  our  very  eyes.  The 
skin  is  cool  and  clammy,  but  the  temperature  from  the  first 
is  high,  102°  to  104°  F.,  and  often  reaches  107°  F.  It  is  some- 
what in  proportion  to  the  severity  of  the  attack.  High  tem- 
perature, as  the  disease  progresses,  points  to  a  fatal  termina- 
tion. The  pulse  is  weak  and  rapid  ;  the  respirations  shallow 
and  fast.  The  tongue  is  coated  early,  but  soon  becomes  dry 
and  red.  -The  abdomen,  instead  of  being  distended,  is  sunken. 
Thirst  is  intense,  the  child  eagerly  taking  any  fluid  given  it. 
The  urine  is  almost  suppressed,  only  very  small  quantities 
being  secreted. 

The  nervous  symptoms  are  marked,  the  child  crying  or 
moaning,  and  throwing  itself  about  in  a  very  restless  way. 
Delirium  and  convulsions  may  follow.  Certain  cases  develop 
the  opposite  condition  of  stupor  and  later  coma.  They  may 
pass  into  a  condition  like  the  algid  stage  of  Asiatic  cholera, 
with  pinched  features,  subnormal  temperature,  collapse,  de- 
pressed fontanelle,  irregular  respiration,  and  very  feeble 
pulse. 

In  some  cases  the  gastro-intestinal  symptoms  subside,  but 
the  nervous  symptoms  become  especially  prominent,  so  much 
so  as  to  suggest  meningeal  complications.  Any  actual 
changes  in  the  brain  or  its  membranes  are,  however,  very  rare. 

('uses  of  cholera  infantum  either  die  or  show  marked 
changes  for  the  better  in  two  or  three  days.  In  those  going 
on  to  recovery  the  vomiting  usually  stops  first,  then  the 
stools  become  less  frequent  and  lose  their  serous  character, 
the  nervous  symptoms  subside,  the  temperature  falls,  and 
the  pulse  and  respiration  regain  their  power.  Convalescence 
i-  likely  to  be  quite  slow. 

Diagnosis:  If  the  picture  of  the  disease  is  kept  well  in 
mind,  it  will  scarcely  be  confounded  with  anything  else. 
Tin'  frequent  vomiting,  large  serous  stools,  high  temperature, 
marked  prostration  and  collapse,  great  thirst,  dry  month  and 
tongue,  combined  with  the  nervous  symptoms  of  great    rest- 


106  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

lessness  or  stupor  and  coma,  and  the  rapid,  feeble  pulse, 
sudden  loss  of  weight,  with  pinched  face  and  sunken  fontan- 
elle,  are  characteristic  of  this  disease  only. 

In  times  of  an  epidemic  of  Asiatic  cholera  there  might  be 
some  difficulty  in  differentiating  these  two  conditions. 

Prognosis :  This  is  distinctly  bad.  If  the  cases  of  real 
cholera  infantum  only  are  considered,  the  mortality  is  prob- 
ably 60  to  70  per  cent.  The  younger  and  feebler  the  child 
the  less  are  its  chances  of  recovery.  The  severity  of  the 
infection  is,  however,  of  most  importance  in  prognosis. 

Cholera  infantum — treatment :  Compare  these  cases  with 
those  of  poisoning  by  some  intense  chemical  irritant  for  pur- 
poses of  treatment.  Prompt  and  energetic  action  should  be 
taken.  First,  not  a  particle  of  food  is  to  be  given  for  twenty- 
four  hours  at  least.  Immediately  and  thoroughly  wash  out 
both  stomach  and  bowels  with  large  quantities  of  boiled  water, 
or  normal  saline  solution.  This  will  not  exhaust  the  patient 
nearly  so  much  as  the  constant  vomiting  and  purging,  and 
assists  nature  in  her  efforts  to  remove  the  poisons  from  the 
system.  After  washing,  tannin  may  be  thrown  into  the 
stomach  and  intestines  to  make  insoluble  compounds  with 
any  of  the  toxins  that  may  be  left  behind.  If  the  vomiting 
and  purging  recur,  repeat  the  washings. 

There  is  very  little  value  in  any  medication  given  by 
mouth  as  it  is  either  ejected  or  not  absorbed.  Stimulants 
will  be  needed,  and  may  be  given  in  the  form  of  whiskey 
diluted  with  cold  water  "by  mouth,  in  small  quantities  fre- 
quently repeated ;  or  hypodermatically.  To  stimulate  the 
heart,  quiet  the  nervous  manifestations,  and  inhibit  the 
enormous  excretion  of  serum  from  the  intestinal  bloodvessels, 
morphine  grain  y^-,  and  atropine  grain  -g-^-,  given  hypoder- 
matically, and  repeated  hourly  to  watch  their  effects,  seem 
the  very  best  combination  yet  suggested.  This  is  contra- 
indicated  only  in  the  cases  with  stupor. 

To  allay  the  great  thirst  and  supply  fluid  to  the  tissues 
normal  salt  solution  is  to  be  injected  slowly  and  in  large  quan- 
tities into  the  subcutaneous  tissues.  Giving  large  amounts 
of  water  by  mouth  only  increases  the  irritability  of  the 
stomach. 


CHRONIC  INTESTINAL  INDIGESTION.  107 

To  combat  the  high  temperature  baths  gradually  cooled 
should  be  used. 

If  the  symptoms  begin  to  abate  and  recovery  seems 
probable,  great  care  should  be  exercised  as  regards  the  return 
to  food,  and  the  strictest  surveillance  of  the  diet  should  be 
kept  up  for  some  weeks.  Recurrences  are  fairly  common 
after  very  slight  dietetic  errors.  The  same  general  rules 
should  be  followed  as  after  recovery  from  fermental  diarrhoea. 
In  the  cases  of  intense  collapse  with  subnormal  temperature 
applications  of  heat  are  decidedly  indicated. 

CHRONIC  INTESTINAL  INDIGESTION. 

Synonyms  :  This  common  form  of  chronic  functional  dis- 
turbance of  the  intestines  is  also  called  chronic  diarrhoea 
and  chronic  intestinal  catarrh. 

Etiology:  It  is  especially  seen  in  institution-children  and 
in  those  massed  together  for  any  cause.  It  is  also  an  accom- 
paniment of  general  constitutional  diseases,  as  rachitis, 
syphilis,  and  chronic  pulmonary  diseases.  It  is  often  seen 
in  children  who  have  been  reduced  by  attacks  of  one  of  the 
acute  infectious  diseases. 

Unhygienic  surroundings  of  any  kind  also  predispose.  It 
may  occur  at  any  season  of  the  year,  but  is  more  serious 
during  hot  weather.  It  attacks  both  breast-fed  and  artifici- 
ally fed  children,  the  latter,  however,  more  commonly.  In 
breast-fed  infants  the  mother's  milk  is  at  fault  in  being  in- 
digestible for  her  particular  child.  Such  mothers  are  usually 
neurotic  or  anaemic,  or  run-down,  or  pregnant,  or  some  of 
the  constituents  of  her  milk  are  present  in  abnormal  quanti- 
ties. Lactation  prolonged  far  beyond  the  normal  time  may 
produce  this  condition. 

In  children  on  the  bottle  too  frequent  feeding,  or  overfeed- 
ing, or  too  concentrated  food  is  usually  the  cause.  A  high 
proteid  percentage  seems  the  commonest  factor.  The  prepared 
foods  containing  starch  may  cause  this  condition. 

In  children  on  general  diet  overuse  of  carbohydrates  seems 
t"  lie  the  commonest  cause.  It  occurs  often  in  children  whose 
feeding  in  early  life   ha-   been   faulty.     Children  allowed  to 


108  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

eat  anything  they  wish — sweets,  pastry,  and  fancy  foods — are 
commonly  affected. 

Pathology :  There  are  really  no  lesions  in  chronic  intestinal 
indigestion,  as  the  condition  is  one  of  chronic  indigestion,  or 
lack  of  performance  of  function  by  the  intestinal  juices,  and 
consequent  fermentative  changes  in  the  undigested  food- 
products.  After  the  disease  has  existed  for  some  time  the 
constant  irritation  in  the  bowels  will  produce  a  mild  form  of 
chronic  catarrhal  inflammation,  evidenced  mainly  by  a  hyper- 
plasia of  the  solitary  and  agminated  follicles  of  the  small 
and  large  gut,  and  by  an  increased  production  of  mucus. 

Chronic  intestinal  indigestion — symptoms  :  A  mild  form  of 
diarrhoea  characterizes  this  condition.  The  stools  seldom  ex- 
ceed six  or  eight  in  the  twenty-four  hours,  and  are  greenish, 
or  yellowish,  or  gray,  and  after  the  diarrhoea  has  existed 
some  time  contain  mucus  and  at  times  streaks  of  blood. 
They  contain  undigested  food,  lumps  of  coagulated  casein, 
and  unchanged  fat.  They  are  very  dry,  or  semisolid  in  con- 
sistency, and  the  odor  is  very  offensive,  an  evidence  of  albu- 
minous decomposition. 

The  child  is  irritable,  nervous,  and  sleeps  badly.  The  ab- 
domen is  markedly  distended  and  tympanitic,  and  the  veins 
on  the  abdominal  wall  are  marked  out  in  their  course.  The 
stomach  is  not  regularly  involved,  and  consequently  vomiting 
is  the  exception.  The  tongue  is  red  and  dry,  and  thrush  and 
stomatitis  are  frequent  complications.  The  skin  of  the  but- 
tocks is  usually  erythematous  and  excoriated.  The  tempera- 
ture may  rise  slightly  and  irregularly,  but  may  be  found  sub- 
normal. The  pulse  grows  rapid  and  feeble,  and  the  respira- 
tion shallow.  The  appetite,  instead  of  being  lost,  is  regularly 
increased,  the  child  taking  its  food  with  seeming  pleasure. 
The  patient  loses  flesh  slowly  but  steadily,  and,  if  the  disease 
is  prolonged,  may  waste  to  a  mere  skeleton.  As  this  condi- 
tion of  emaciation  develops  the  patients  lie  in  a  semistupor, 
sucking  their  fingers  and  otherwise  indifferent  to  their  sur- 
roundings. 

The  duration  of  the  cases  is  very  indefinite,  exacerbations 
and  remissions  being  common. 

In  children  on  general  diet  the  skin  is  pale  and  callow,  the 


CHRONIC  INTESTINAL  INDIGESTION.  109 

muscles  are  flabby,  the  whole  body  is  thin,  but  the  abdomen 
is  protuberant  and  distended.  These  children  are  emotional, 
cross,  and  hard  to  control.  Their  sleep  is  restless  and  dis- 
turbed, and  during  sleep  they  frequently  grind  their  teeth. 
The  bowels  may  be  constipated,  with  light-gray  lumpy  stools 
of  a  foul  odor,  and  an  excessive  quantity  of  gas ;  or  diarrhoea 
may  exist  with  four  or  five  stools  a  day  containing  undigested 
food  and  with  an  offensive  smell.  They  may  at  times  con- 
tain mucus.  Colicky  pains  are  frequent.  The  appetite  is 
variable,  with  a  craving  for  indigestible  articles  of  food.  The 
tongue  is  thickly  coated  white  and  the  breath  is  bad. 

There  are  many  nervous  symptoms,  in  addition  to  the  emo- 
tional changes,  as  tetany,  fainting-attacks,  headache,  dulness, 
stupor,  and  at  times  convulsions.  There  is  often  slight  irregu- 
lar fever. 

Diagnosis :  The  history,  with  examination  of  the  child  and 
inspection  of  the  stools,  usually  quickly  establishes  the  diag- 
nosis. Special  attention  should  be  given  to  the  other  organs 
to  prove  the  presence  or  absence  of  disease  of  any  of  them. 
Marasmus  and  tuberculosis  especially  must  be  differentiated. 

Prognosis  :  Without  intelligent  care  cases  of  chronic  intes- 
tinal indigestion  continue  to  grow  worse  and  die  from  ex- 
haustion or  from  some  intercurrent  acute  diarrhoea,  or  pul- 
monary disease.  If  the  disease  is  in  a  child  with  some 
constitutional  disorder,  or  in  an  institution,  the  prognosis  is 
bad.  If  the  child  is  strong,  and  if  intelligent  treatment  can 
be  carried  out  by  removing  the  cause,  recovery  should  take 
place.  The  younger  the  child  the  fewer  the  chances  for  re- 
covery. The  disease  is  more  difficult  to  cure  in  the  summer 
time  than  during  cold  weather. 

In  children  on  general  diet  a  fatal  ending  is  not  common, 
but  a  permanent  relief  of  the  symptoms  is  difficult  to 
accomplish  ;  and  these  cases  grow  to  adult  life  with  digestive 
systems  that  are  always  troublesome. 

Chronic  intestinal  indigestion — treatment :  The  2yveven^'n'<' 
treatment  is  most  important,  and  consists  in  strict  attention 
to  the  feeding  on  hygienic  principles  of  all  infants  and  young 
children. 

If  the  disease  has  started,  the  dietetic  and  hygienic  manage- 


110  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

ment  is  far  more  important  than  any  drugs.  Seek  hard  for 
the  cause  in  the  food  the  child  is  taking:.  Have  a  chemical 
analysis  of  the  milk,  breast  or  cows',  made  to  find  what  con- 
stituent is  at  fault.  Inspect  the  stools  to  find  what  forms  of 
food  are  most  undigested.  Regulate  the  quantity  of  food 
and  the  intervals  of  feeding,  as  well  as  the  quality.  If  any 
constitutional  ailments  are  present,  treat  them.  Have  the 
child  properly  clothed  for  the  season  of  the  year.  If  it  is 
summer,  insist  on  change  of  climate  if  possible.  At  any 
rate,  have  plenty  of  fresh  air  with  sanitary  surroundings. 

It  is  often  helpful  to  put  an  artificially  fed  child  on  some 
non-milk  food  for  some  time,  and  whatever  food  is  given 
should  be  well  diluted.  Egg-water,  whey,  broths,  or  one  of 
the  non-starchy  proprietary  foods  may  be  tried.  The  pre- 
digested  foods,  peptonized  milk,  or  peptonoids,  find  a  useful 
field  in  these  cases.  It  is  better  to  underfeed  than  to  over- 
feed these  children. 

As  regards  drugs,  none  is  very  satisfactory.  Opium  and 
astringents  are  useless.  The  only  cases  wdiere  opium  is  indi- 
cated are  those  in  which  the  bowels  move  immediately  on  the 
introduction  of  food  into  the  mouth.  Here  it  counteracts 
the  reflexly  increased  peristalsis.  The  intestinal  antiseptics 
may  be  helpful :  bismuth  subnitrate  in  large  doses,  or  salol, 
or  salicylate  of  sodium.  Dilute  hydrochloric  acid  and  pepsin 
given  with  each  feeding  are  theoretically  indicated.  Calomel 
in  divided  doses,  or  castor  oil,  from  time  to  time,  are  good 
adjuvants.  An  occasional  thorough  washing  of  the  colon  is 
advisable.  As  improvement  begins  tonics,  as  iron  and 
arsenic,  are  indicated. 

In  children  on  general  diet  results  of  treatment,  if  care- 
fully carried  out,  are  brilliant.  The  regulation  of  the  diet  is 
here  also  of  primary  importance.  A  diet  of  beef-juice,  or 
scraped  beef,  or  partially  peptonized  milk,  with  avoidance  of 
carbohydrate  food  and  absolute  prohibition  of  all  indigestible 
and  fancy  foods,  will  accomplish  wonders  in  these  children. 
The  proprietary  foods  here  have  a  useful  field.  The  meals 
should  be  given  at  regular  intervals.  As  improvement  occurs, 
a  gradual  return  to  the  diet  proper  for  a  child  of  its  age 
should  be  substituted. 


ACUTE  ENTERO-COLITIS.  Ill 

Calomel  given  from  time  to  time  aids  our  treatment,  espe- 
cially in  the  constipated  cases,  and  colon-irrigation  may  be 
helpful,  particularly  in  the  cases  with  mucus.  Salol  or 
sodium  salicylate  may  aid  in  lessening  flatulence.  Tincture 
of  mix  vomica  is  a  useful  tonic.  Regular  exercise  and  fresh 
air,  and  a  general  sanitary  life,  must  be  included  in  our 
management.     Relapses  will  follow  slight  indiscretions. 

ACUTE  ENTERO-COLITIS. 

Definition  and  synonyms  :  So  far,  all  the  forms  of  diarrhoea 
described  have  been  essentially  without  anatomical  lesions,  but 
depend  rather  on  changes  taking  place  in  the  food  than  in  the 
intestinal  walls.  This  form,  on  the  contrary,  is  really  an  in- 
flammation of  the  intestinal  mucous  membrane.  Other 
names  by  which  it  is  known  are  ileo-colitis,  enteritis,  dysen- 
tery, and  inflammatory  diarrhoea. 

Acute  entero-colitis — etiology:  The  causes  are  virtually  the 
same  as  those  of  fermental  diarrhoea  :  bad  food,  or  bad  habits 
of  feeding,  being  of  the  greatest  importance.  Hot  weather 
predisposes  markedly  to  the  disease,  although  in  the  fall,  with 
exposure  to  cold,  many  cases  develop.  It  is  frequently  the  re- 
sult of  one  of  the  forms  of  functional  diarrhoea  which  has  been 
improperly  cared  for.   It  may  complicate  the  infectious  diseases. 

Bacterial  life  of  some  kind  undoubtedly  plays  a  prominent 
part  in  its  etiology.  It  is  far  most  frequent  in  artificially  fed 
children,  and  the  tendency  to  it  exists  even  after  general  diet 
is  allowed. 

Pathology  :  The  lesions  of  acute  entero-colitis  are  found  in- 
volving, as  a  rule,  both  the  ileum  and  the  colon,  spreading  in 
both  directions  from  the  ileo-csecal  valve.  In  a  few  cases 
the  ileum  only,  in  a  larger  number  the  colon  only,  is  involved. 

The  mildest  cases  show  only  a  catarrhal  inflammation  of  the 
mucous  membrane,  with  swelling,  congestion,  and  increased 
production  of  mucus.  The  veins  are  engorged,  and  large 
areas  of  the  mucous  membrane  appear  of  a  deep-red  color. 
In  places  small  hemorrhagic  spots  may  be  seen. 

In  the  protracted  cases  the  entire  intestinal  wall  is  thickened, 
and  the  solitary  follicles  and   I 'oyer's  patches  are  swollen. 


112  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

If  this  catarrhal  inflammation  is  very  severe  and  long  con- 
tinued, small  ulcers  appear  in  the  mucous  membrane,  due  to 
desquamation  of  the  epithelium.  These  are  scattered  irregu- 
larly through  the  colon.  Several  of  these  ulcers  may  coalesce, 
forming  large  irregular  bare  areas.  By  this  process  large 
amounts  of  the  mucous  membrane  may  be  destroyed,  and  the 
gut  present  a  worm-eaten  appearance. 

Other  cases  present  the  lesions  of  inflammation  and  hyper- 
plasia, with  subsequent  breaking  down  of  the  solitary  lymph- 
follicles.  These  changes  are  seen  in  both  the  ileum  and  the 
colon.  Peyer's  patches  may  also,  but  rarely,  be  involved. 
Seen  with  the  naked  eye  the  mucous  membrane  is  studded 
with  little  rounded  elevations,  the  enlarged  follicles,  and  in 
the  early  stages  the  top  of  each  presents  a  small  pit.  In 
more  advanced  cases  the  excavation  is  larger  and  the  elevation 
smaller,  the  follicles  having  been  entirely  destroyed.  The 
mucous  membrane  then  presents  a  uniformly  pitted  appear- 
ance. The  ulcers  do  not  become  large  like  those  in  catarrhal 
ulceration,  but  at  times  two  or  more  small  ulcers  may  run 
together  and  form  an  irregular  figure.  The  mucous  mem- 
brane is  never  so  completely  destroyed  as  in  the  former  ulcera- 
tive condition. 

Another  and  the  most  severe  form  of  entero-colitis  shows 
the  lesions  of  croupous  inflammation.  In  this  there  are  patches 
of  false  membrane  adhering  to  the  surface  of  the  intestine. 
To  the  naked  eye  the  intestinal  wall  is  thick  and  stirrer  than 
normal,  and  has  a  greenish  appearance  on  its  inner  surface. 
It  is  difficult  to  strip  off  any  large-sized  pieces  of  the  mem- 
brane from  its  base.  The  portions  of  gut  uncovered  by. 
pseudo-membrane  are  red  and  congested,  with  here  and  there 
hemorrhagic  spots.  The  lesions  are  most  marked  in  the  colon, 
but  some  patches  may  be  found  above  the  ileo-csecal  valve. 
Under  the  microscope  a  distinct  layer  of  fibrinous  exudate  is 
seen  growing  on  the  intestinal  mucous  membrane.  There  is 
a  large  round-cell  infiltration  of  the  mucosa  and  submucosa. 
Necrosis  and  ulceration  are  very  rare. 

There  are  many  complicating  lesions,  as  bronchitis,  broncho- 
pneumonia, atelectasis,  and  acute  degenerative  nephritis.     The 


ACUTE  ENTERO-COLITIS.  113 

mesenteric  lymph-nodes  are  enlarged  and  inflamed  in  almost 
every  case. 

Acute  entero-colitis — symptoms :  Some  attempt  may  be 
made  to  connect  certain  symptoms  with  one  or  other  of  the 
groups  of  pathological  lesions  just  described;  but  the  cases 
vary  excessively  in  their  clinical  picture,  and  such  attempts 
are  often  proved  ineffectual  at  the  autopsy. 

The  cases,  except  in  the  follicular  form,  which  is  more  of 
a  subacute  process,  begin  suddenly  with  vomiting,  diarrhoea, 
abdominal  pain,  and  fever. 

The  stools  at  first  are  fsecal,  but  soon  become  mixed  with 
blood  and  mucus  in  considerable  quantities.  They  are  very 
frequent,  each  one  small  in  amount,  and  are  preceded  by 
pain  and  followed  by  rectal  tenesmus.  There  is  very  little 
disagreeable  odor  to  these  stools,  the  odor  occurring  in  the 
late  stools  of  prolonged  cases.  In  the  follicular  variety  the 
stools  are  less  frequent  and  the  presence  of  blood  less  com- 
mon. In  the  membranous  variety  mucus  and  blood  are  pres- 
ent in  large  quantities,  and  shreds  of  pseudo-membrane  add 
a  diagnostic  feature  to  the  case.  After  a  few  days,  in  all  the 
cases,  the  stools  gradually  assume  a  dark-brown  or  greenish- 
brown  color.  Prolapsus  ani  frequently  complicates  the  pro- 
tracted cases. 

The  temperature  at  first  averages  103°  or  104°  F. ;  but  as 
the  disease  progresses  it  falls  some,  but  continues  above  nor- 
mal so  long  as  the  inflammatory  process  is  present.  In  the 
beginning  the  patients  are  less  prostrated  than  in  the  fer- 
mentative diarrhoeas;  but  as  the  case  progresses  the  prostra- 
tion increases. 

There  is  anorexia,  but  increased  thirst.  The  abdomen  is 
distended,  and  usually  tender  along  the  line  of  the  colon. 

The  child  gradually  /o.sr.s  flesh  and  strength,  the  pulse  be- 
comes  rapid  and  feeble,  and  the  respirations  irregular  and 
shallow.  The  skin  of  the  buttocks  becomes  excoriated,  and 
bedsores  may  form.  The  tongue  is  coated, or  red  and  glazed, 
and  the  mouth  is  frequently  the  seat  of  some  variety  of  stom- 
atitis. 

Nervous  symptoms  in  the  early  stages  are  of  an  active  na- 
8— D.  C 


114  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

ture :  restlessness,  irritability,  twitchings,  and  convulsions. 
If  the  case  lasts,  stupor  and  coma  often  develop. 

The  more  acute  cases  die  in  a  few  days  to  a  couple  of  weeks. 
The  subacute  cases  may  last  three  or  four  weeks,  gradually 
losing  ground  till  death. 

In  cases  of  recovery  the  early  symptoms  of  improvement 
are  seen  in  the  stools  :  the  mucus  and  blood  gradually  disap- 
pear, the  movements  are  less  frequent,  and  the  constitutional 
symptoms  subside  by  degrees.  Convalescence  in  all  varieties 
is  very  slow  and  relapses  are  common. 

Diagnosis  :  The  two  diseases  with  which  acute  entero-colitis 
may  be  confounded  are  typhoid  fever  and  intussusception.  The 
former  is  rare  in  children,  but  must  be  remembered  during 
an  epidemic.  The  latter  should  always  be  thought  of,  as  the 
symptoms  of  the  two  are  similar  :  abdominal  pain,  tenesmus, 
bloody  discharges,  and  vomiting.  The  fever  of  entero-colitis 
is  not  present  in  intussusception,  and  the  subsequent  consti- 
pation and  presence  of  an  abdominal  tumor  in  the  latter  con- 
dition are  differential  points. 

The  effort  to  separate  the  different  pathological  varieties  of 
entero-colitis  depends  on  the  onset  and  severity  of  the  symp- 
toms and  the  characters  of  the  stools.  Many  cases  cannot  be 
classified  even  with  all  the  helps. 

Prognosis :  The  prognosis  of  acute  entero-colitis  is  always 
grave,  but  is  worse  in  feeble  or  anaemic  children,  and  in  those 
already  suffering  from  any  form  of  constitutional  or  nutri- 
tional disorder,  as  rickets,  syphilis,  tuberculosis,  or  marasmus. 
The  younger  the  child  the  more  are  the  chances  of  an  un- 
favorable end.  Protracted  cases  and  those  occurring  in  hot 
weather  have  a  bad  prognosis.  In  a  previously  healthy  child 
and  under  proper  surroundiugs,  with  an  intelligent  carrying 
out  of  the  physician's  directions,  many  cases  will  recover. 
Never  forget  the  possibility  of  a  relapse  occurring  even  when 
the  child  is  seemingly  improving  rapidly. 

Acute  entero-colitis — treatment:  In  the  way  of  prevention, 
special  attention  should  be  paid  to  the  careful  feeding  of  all 
children  during  their  years  of  liability  to  the  disease.  All 
the  hygienic  and  sanitary  surroundings  of  the  children  should 
be  regulated  to  the  best  of  our  ability  in  each  particular  case. 


ACUTE  ENTERO-COLITIS.  115 

Prompt  treatment  of  all  the  forms  of  functional  diarrhoeas 
will  prevent  the  development  of  many  cases  of  these  graver 
varieties. 

If  a  case  has  developed,  a  change  of  air  to  a  cooler  climate 
will  often  work  marked  and  rapid  improvement.  The  die- 
tetic regulations  are  most  important  and  most  difficult.  In 
breast-fed  babies,  if  no  gross  changes  are  evident  in  the  milk, 
this  form  of  feeding  should  not  be  interfered  with.  If  a 
child  has  been  recently  weaned,  a  wet-nurse  may  be  needed. 
In  bottle-fed  babies  the  milk  should  be  made  quite  dilute  or 
be  peptonized,  or  stopped  altogether,  and  meat-juice,  broths, 
scraped  beef,  peptonoids,  or  egg-,  rice-,  or  barley-water  used 
instead.  The  point  is  to  give  food  that  leaves  very  little 
indigestible  residue.  These  children  have  little  appetite, 
and  enough  food  must  be  given  to  keep  up  their  nutrition. 
All  food  should  be  given  at  regular  intervals,  and  not  too 
often.  As  improvement  occurs  special  care  should  be  given 
to  the  diet  to  prevent  relapses. 

In  the  beginning  lavage,  performed  once,  may  be  useful ; 
it  will  seldom  require  repetition.  Irrigation  of  the  colon  is 
particularly  valuable  in  this  condition.  The  lesions  are 
mostly  colonic,  and  we  can  make  our  medication  through 
local  applications  direct.  A  normal  salt  solution  given  warm 
with  a  high  rectal  tube,  and  in  considerable  quantities,  injected 
once  or  twice  a  day  is  the  safest  solution.  Tannin  or  starch 
may  be  added.  It  is  unsafe  to  use  the  stronger  antiseptics 
for  fear  of  leaving  some  behind.  If  tenesmus  is  marked, 
starch-water  with  the  addition  of  five  or  ten  drops  of  lauda- 
num is  very  soothing.  Cocaine  suppositories,  each  containing 
one-fourth  to  one-half  grain  of  the  drug,  may  be  needed. 

At  the  first,  a  good-sized  dose  of  castor  oil,  one  or  two 
drachms,  should  be  given  if  the  stomach  will  retain  it.  Later, 
repeated  doses  of  the  same  in  small  quantities,  ten  to  fifteen 
minims,  will  often  be  found  beneficial.  Opium  in  one  form 
or  another  will  usually  be  needed  after  the  purge  has  acted. 
It  is  always  best  given  separately,  in  small  doses,  repeated  as 
need  requires  to  quiet  the  pain  and  tenesmus.  Bismuth  in 
large  doses  regularly  repeated,  fifteen  to  twenty  grains  every 
three  or  four  hours,  soothes  and  rests  the  inflamed  mucous 


116  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

membrane.  Stimulants  are  almost  always  necessary  to  rouse 
the  feeble  circulation  and  combat  the  great  prostration. 
Blackberry  brandy,  whiskey,  or  good  old  brandy  may  be 
used.  Pepsin  and  the  mineral  acids  are  frequently  given  by 
mouth  for  assistance  in  more  completely  digesting  the  food. 

As  convalescence  is  established,  the  mineral  acids,  nux 
vomica,  arsenic,  and  iron  are  helpful  tonics,  local  and  general. 
After  complete  recovery  in  the  digestive  tract  cod-liver  oil 
is  useful. 

CHRONIC  ENTERO-COLITIS. 

Definition  :  These  are  prolonged  uncured  cases  of  the  acute 
form  of  entero-colitis,  which  have  lost  their  active  character. 
The  change  from  the  acute  to  the  chronic  condition  is  slow 
and  gradual,  and  the  point  of  change  is  hard  to  set. 

Etiology :  Bad  management  of  acute  cases  of  entero-colitis 
is  usually  the  cause  of  the  assumption  of  a  chronic  character. 
It  is  seen  in  the  more  hardy  infants,  who  have  managed  to 
escape  death  during  the  summer  months. 

Pathology :  The  main  lesions  found  are  a  chronic  catarrhal 
inflammation  of  the  mucous  membrane,  with  growth  of  new 
connective  tissue,  and  destruction  of  the  tubular  glands  of 
the  intestine;  or  a  chronic  hyperplasia  of  the  lymph-follicles 
with  some  small  ulcerations  over  their  summits  and  marked 
pigmentation  in  places.  Ulcerative  conditions  are  rare,  as 
most  of  the  patients  with  ulceration  die  during  the  acute 
stage.  Chronic  pulmonary  complications  are  common — hypos- 
tatic congestion,  broncho-pneumonia,  or  tuberculosis. 

Chronic  entero-colitis — symptoms :  There  are  no  fever  and 
no  signs  of  active  inflammation.  Pain  and  tenderness  have 
likewise  disappeared.  Food  is  taken  readily  as  given  ;  but 
evidences  of  a  desire  for  it  are  not  common.  The  main 
symptoms  are  progressive  emaciation  and  abnormal  bowel- 
action.  The  child  wastes  from  week  to  week,  until  there 
seems  nothing  to  its  body  but  the  skeleton  covered  with 
loose  skin.  The  face  is  thin  and  sharp,  the  eyes  sunken,  and 
the  cheeks  hollow.  The  fontanelle  is  much  depressed.  All 
the  subcutaneous  fat  has  disappeared,  so  that  the  skin  hangs 
in  loose  folds.     The  abdomen  is  distended  and  tympanitic. 


CHRONIC  ENTERO-COLITIS.  Ill 

The  lips,  tongue,  and  mouth  are  usually  dry,  and  may  be 
covered  with  sordes.  Various  forms  of  stomatitis  may  be 
present.  The  teeth  may  decay  rapidly,  but  dentition  may 
proceed  normally.     Vomiting  is  rare. 

The  stools  average  four  to  six  per  day  ;  they  are  thin,  and 
contain  mucus  and  biliary  coloring-matter,  being  green  or 
brown.  They  contain  undigested  food  unless  the  diet  is  care- 
fully regulated.  Blood  is  seldom  present.  They  have  a  very 
offensive  putrid  odor.  Prolapsus  ani  is  rarer  than  in  the 
acute  variety  of  the  disease.  Colic  and  flatulence  are  regular 
accompaniments.  The  skin  around  the  buttocks  is  erythem- 
atous and  excoriated. 

The  pulse  is  rapid  and  feeble,  the  circulation  sluggish,  and 
the  extremities  cold.  These  children  are  restless  and  irri- 
table, sleep  poorly,  and  whine  a  great  deal.  At  other  times 
they  are  dull  and  stuporous.     Convulsions  may  occur. 

The  duration  of  the  cases  is  a  few  months. 

Diagnosis  :  The  main  point  to  be  determined  is  whether  the 
symptoms  are  due  only  to  the  chronic  entero-colitis,  or  whether 
there  is  some  complicating  disease.  Rickets,  syphilis,  tubercu- 
losis, and  marasmus  must  each  be  carefully  examined  for  and 
excluded. 

Prognosis  :  This  is  very  bad  in  young  infants,  in  those  pre- 
viously debilitated,  in  those  in  institutions  ;  and  during  hot 
weather.  Under  favorable  circumstances,  and  when  intelli- 
gent treatment  can  be  followed,  results  are  fair.  Some  of  the 
most  hopeless  appearing  cases  recover. 

Chronic  entero-colitis — treatment :  The  main  reliance  is  on 
good  hygiene,  carefully  regulated  diet,  and  local  treatment  of 
the  colon.  An  occasional  dose  of  castor  oil  to  clean  out  the 
entire  intestinal  tube;  opium  from  time  to  time  when  the 
peristalsis  is  excessive;  and  stimulants  judiciously  used,  are 
the  only  drugs  of  any  special  value. 

The  sanitary  points  to  be  taken  advantage  of  are  abundance 
of  fresh  air,  a  change  of  climate,  regular  bathing,  and 
cleanliness. 

The  diet  should  be  nourishing,  suitable  lor  the  age  of  (ho 
child,  and  cither  very  casv  of  digestion  or  predigested.  Pep- 
tonized milk,  beef-juice,  scraped  beef,  peptonoids,  and  such 


118  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

forms  of  highly  nutritious  food  leaving  little  residue  are 
specially  useful.  Attempt  to  keep  up  the  child's  nutrition 
without  overfeeding. 

Astringent  applications  given  regularly  by  means  of  ene- 
mata  seem  the  most  useful  form  of  medication.  They  should 
be  used  daily,  and  such  solutions  as  tannin,  alum,  boric  acid, 
or  silver  nitrate  may  be  employed.  Changing  the  drug  used 
in  the  enemata  from  time  to  time  seems  helpful.  Bismuth 
may  be  given  by  mouth,  as  also  pepsin ;  but  brilliant  results 
need  not  be  expected  from  either. 

CHRONIC  TUBERCULAR  ENTERITIS. 

Occurrence  :  This  condition  is  found  usually  associated  with 
tuberculosis  elsewhere  in  the  body,  but  in  some  few  cases  may 
be  primary.  The  mesenteric  lymph-glands  are  always  coin- 
cidently  involved. 

Etiology :  The  tubercle  bacillus  in  the  intestinal  canal  is  the 
cause  of  this  condition.  The  bacilli  may  be  swallowed  in 
sputum  from  the  infected  lung  or  in  milk. 

Chronic  tubercular  enteritis — pathology :  The  lesions  of 
chronic  tubercular  enteritis  are  usually  found  only  in  the 
small  intestine,  and  consist  of  tubercular  deposits  in  the 
solitary  and  agminated  lymph-follicles,  and  of  necrosis  of 
these  with  formation  of  ulcers.  These  ulcers  are  irregularly 
shaped,  and  lie  transverse  to  the  length  of  the  gut.  They 
vary  greatly  in  number  and  size.  The  lymph-glands  are 
enlarged,  and  may  caseate  and  form  abscesses. 

Chronic  tubercular  enteritis — symptoms :  There  may  be 
diarrhoea  or  constipation,  the  former  being  the  more  com- 
mon. Diarrhoea  in  general  tuberculosis  does  not  always  have 
ulcers  as  its  cause.  If  diarrhoea  is  present,  it  is  very  obstinate. 
Hemorrhages  are  rare,  but  may  be  serious.  The  stools  are 
large,  frequent,  and  brown.  Abdominal  pain  may,  or  may 
not,  be  present.  There  are  progressive  wasting,  and  fever 
with  its  accompanying  symptoms. 

Diagnosis  :  This  depends  on  finding  the  tubercle  bacillus  in 
the  stools.  In  any  case  of  tuberculosis  with  diarrhoea  the 
probabilities  are  in  favor  of  ulceration  being  present. 


APPENDICITIS.  119 

Prognosis :  This  is  distinctly  bad.  As  a  complication  it 
makes  the  fatal  end  of  pulmonary  tuberculosis  more  rapid, 
due  to  its  interference  with  the  nutrition.  If  primary,  it 
will  probably  lead  to  infection  elsewhere. 

Chronic  tubercular  enteritis — treatment :  The  diarrhoea  is 
best  treated  by  combinations  of  bismuth  and  opium.  Intes- 
tinal irrigation  is  not  used,  as  the  lesions  are  seldom  in  the 
colon.  Creosote  is  useful,  as  in  all  forms  of  tuberculosis. 
Stimulants  will  usually  be  necessary. 

APPENDICITIS. 

"  Appendicitis "  is  now  used  to  include  all  varieties  of 
inflammation  occurring  in  the  region  of  the  csecum,  as  they 
are  all  now  believed  to  originate  in  the  appendix  vermiformis. 

Etiology :  Appendicitis  is  commoner  in  males  than  in 
females,  and  is  usualy  seen  in  young  adults.  After  the  fourth 
year  of  life  it  is  fairly  frequent,  although  cases  are  reported 
from  time  to  time  even  under  four  years,  and  one  is  recorded 
only  seven  weeks  old. 

Predisposing  causes  are  the  anatomical  peculiarities  of  the 
appendix,  such  as  unusual  length,  abnormal  position,  and 
irregularities  of  the  mesentery.  These  all  tend  to  prevent 
the  appendix  from  expelling  its  contents.  Adhesions  from 
previous  inflammations  act  in  the  same  way.  Chronic  con- 
stipation also  acts  as  a  predisposing  cause. 

Exciting  causes  are  usually  mechanical — the  presence  of  a 
faecal  concretion  or  a  foreign  body  in  the  appendix.  Blows, 
falls,  or  strains,  with  the  presence  of  such  a  foreign  body, 
act  as  frequent  causes.  Undoubtedly  there  is  a  bacterial  ele- 
ment of  much  importance  in  the  etiology;  but  as  yet  its  ex- 
act connection  with  each  case  is  not  well  worked  out.  Each 
c;[M'  \<  probably  due  primarily  to  some  mechanical  cause  in- 
terfering with  the  circulation  in  the  appendix,  followed  by  a 
germ  infection  made  more  easy  by  this  stasis. 

Pathology:  The  appendix  may  be  the  seat  of  a  simple  catar- 
rhal inflammation  only,  with  congestion  and  swelling  of  the 
mucous  membrane,  ami  increased  production  of  mucus.  In 
these  mild  cases  resolution  takes  place  with  few  symptoms 
and  a  normal  appendix. 


120  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

If  the  inflammation  is  more  severe,  the  appendix  becomes 
distended  with  the  inflammatory  products,  and  the  lumen  of 
the  tube  closed  up.  In  these  cases  the  peritoneal  coat  is  in- 
volved as  well  as  the  mucous  membrane,  and  from  this  a 
localized  or  general  peritonitis  may  arise  by  contact,  and 
without  perforation.  The  mucous  membrane  is  likely  to  be 
ulcerated,  even  when  no  foreign  body  is  present.  In  recovery 
from  these  cases,  strictures  of  the  lumen,  bendings  and  thick- 
enings of  the  walls  of  the  appendix,  and  peritoneal  adhesions 
are  left  behind.     Recurrences  are  frequent  after  such  attacks. 

In  still  more  severe  cases  the  inflammation  and  swelling  are 
so  intense  as  to  cause  necrosis  and  sloughing  in  the  wall  of 
the  appendix,  with  perforation  at  one  or  more  points.  These 
perforations  lead  to  a  localized  abscess  if  adhesions  are  pres- 
ent, or  to  a  general  peritoneal  infection  if  not. 

There  is  a  form  of  appendicitis  in  which  the  entire  appen- 
dix becomes  rapidly  gangrenous,  with  general  peritonitis  as 
an  immediate  complication.  The  whole  appendix,  or  a  por- 
tion, may  become  completely  detached. 

Inflammation  and  ulceration  caused  by  the  typhoid  or 
tubercle  bacilli   are  found  in  the  appendix  at  times. 

Appendicitis — symptoms :  The  disease  usually  begins  with 
general  abdominal  pain,  which  sooner  or  later  is  localized  in 
the  region  of  the  caecum.  With  the  pain  there  are  fever  of  a 
moderate  degree,  at  times  a  chill,  some  rapidity  of  the  pulse, 
and  nausea  or  vomiting.  The  bowels  are  usually  constipated, 
but  there  may  be  diarrhoea. 

On  examination  there  is  tenderness  in  the  right  iliac  region, 
and  this  can  usually  be  localized  in  one  small  area,  called 
"  McBurney's  point,"  one-third  of  the  distance  on  a  line 
drawn  from  the  right  anterior  superior  spine  of  the  ileum  to 
the  navel.  The  right  rectus  muscle  offers  some  resistance  to 
palpation. 

If  more  severe,  and  the  whole  appendix  is  inflamed,  with 
some  localized  peritonitis,  the  symptoms  are  more  marked, 
and  on  palpation  fulness  and  an  indistinct  feeling  of  a  mass 
in  the  right  iliac  fossa  can  be  made  out.  If  perforation  with 
a  localized  abscess  results,  a  distinct  mass,  dull  on  percussion, 
is  found. 


APPENDICITIS.  121 

The  suddenly  perforating  and  gangrenous  cases  may  give 
no  signs  in  the  beginning  different  from  the  milder  attacks, 
and  may  suddenly  show  all  the  symptoms  of  a  diffuse  peri- 
tonitis with  general  septic  infection.  There  is  very  great 
difficulty  in  deciding  in  the  early  stages  which  are  to  be  the 
mild  and  which  the  severe  cases.  No  one  symptom  can  be 
relied  on  to  warn  us  of  this,  and  hence  the  general  picture  of 
every  case  must  be  carefully  and  intelligently  watched. 

Perforation  and  gangrene  usually  succeed  to  a  few  days  of 
the  milder  symptoms  ;  but  they  may  occur  in  the  early  stages. 
They  are  evidenced  by  a  sudden  increase  in  the  pain,  by 
vomiting,  a  rapid  rise  in  the  pulse,  and  the  symptoms  of 
intense    shock. 

The  temperature  usually  rises  also.  If  the  general  peri- 
toneal cavity  is  shut  off  by  adhesions,  the  acute  symptoms 
gradually  subside,  and  the  patient  is  left  with  the  presence  of 
a  circumscribed  abscess.  This  abscess,  if  left  alone,  may 
perforate  the  colon,  the  bladder,  or  the  peritoneal  cavity,  or 
may  travel  behind  the  peritoneum  backward,  upward,  or 
downward.  If  no  adhesions  are  present,  the  symptoms  of 
shock  are  rapidly  replaced  by  those  of  general  peritonitis,  and 
death  follows  in  a  few  days. 

After  recovery  from  a  primary  attack  the  patient  may  have 
more  or  less  frequent  recurrent  attacks  of  exactly  the  same 
character  as  the  first  one.  The  symptoms  and  prognosis  in 
these  recurrences  are  the  same  as  in  the  primary  attack. 

Other  cases  have  no  more  acute  attacks,  but  suffer  from  a 
chronic  disturbance,  with  pain  and  uneasiness,  in  the  region 
of  the  appendix.  Some  of  these  patients  tend  to  become 
chronic  invalids. 

Diagnosis  :  Remember  how  almost  impossible  it  is  to  decide 
what  pathological  condition  exists  in  the  appendix  from  the 
symptoms  and  physical  signs  in  the  early  stages.  Reliance 
cannot  positively  be  placed  on  anything. 

In  differentiating  appendicitis  from  other  conditions  in  chil- 
dren, ordinary  colic  and  intussusception  are  most  likely  to 
cause  confusion.  In  colic  there  is  no  fever  and  no  tender- 
ness. On  the  contrary,  pressure  ordinarily  relieves  the  pain. 
In  intussusception  there  is  no  fever  in  the  beginning,  and  the 


122  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

resistance  or  tumor  is  in  the  upper  portion,  on  the  left  side  of 
the  abdomen  rather  than  the  right.  Further,  the  tenesmus 
and  bloody  discharges  from  the  rectum  are  absent  in  appen- 
dicitis. 

Prognosis  :  This  is  always  grave  ;  but  many  cases  recover 
under  both  medical  and  surgical  treatment.  If  the  case  can 
be  properly  treated  before  general  peritonitis  develops,  the 
chances  for  cure  are  good.  Localized  abscesses  are  favorable 
for  cure.     General  peritonitis  is  uniformly  fatal. 

Appendicitis — treatment :  The  child  should  be  kept  abso- 
lutelv  at  rest  in  bed,  put  on  a  fluid  diet,  and  an  ice-bag 
applied  continuously  to  the  right  iliac  region.  If  ice  is 
objectionable  to  the  patient's  sensations,  hot  poultices  may  be 
substituted.  Opium  may  be  given  in  small  quantities,  but 
enough  to  relieve  the  pain  if  the  local  applications  fail  to  do 
so.  No  cathartics  should  be  given,  but  enemata  may  be  used 
as  needed. 

It  is  wise  for  a  physician  and  a  surgeon  to  watch  these 
cases  together  from  the  outset,  as  operation  may  be  demanded 
at  any  time.  When  skilled  surgical  help  is  available  there  is 
less  risk  in  operating  on  a  doubtful  case  than  in  delaying  the 
operation  too  long.  The  difficulty  in  deciding  how  a  case 
will  develop  has  much  to  do  with  the  varying  opinions  of 
physicians  and  surgeons  as  to  the  place  of  operative  inter- 
ference in  dealing  with  these  cases. 

If  an  abscess  is  present,  an  operation  is  indicated  at  once. 

COLIC. 

"  Colic  "  is  a  name  for  a  symptom  only ;  but  it  is  so  com- 
mon in  infancy,  and  so  often  requires  treatment  of  itself,  that 
a  separate  description  is  usually  accorded  it. 

Etiology :  Colic  is  a  regular  symptom  of  almost  all  the 
functional  and  inflammatory  diarrhoeas,  of  appendicitis,  of 
intussusception,  and  of  worms.  It  may  be  present,  however, 
without  diarrhoea,  vomiting,  obstruction,  or  foreign  bodies ; 
and  in  these  cases  is  due  to  flatulent  distention  of  the  intes- 
tine and  irregular  peristalsis.  The  distending  gases  are 
formed  by  fermentative  changes  in  the  food-contents  of  the 


COLIC.  123 

alimentary  canal.  It  may  occur  in  both  breast-fed  and  arti- 
ficially fed  babies  ;  but  is  commoner  in  the  latter  class.  In 
either  case  the  food  contains  some  indigestible  constituent, 
and  this  is  usually  the  proteids.  Starchy  foods  may  be  the 
cause,  and  also  over-feeding.  Chronic  constipation  is  fre- 
quently present.  Colic  is  most  frequent  during  the  early 
months  of  life. 

Pathology  :  The  condition  is  one  of  painful  muscular  con- 
traction of  the  intestinal  walls  in  the  endeavor  to  remove  the 
accumulated  distending  gases. 

Colic — symptoms  :  These  are  crying,  which  is  sharp  and  per- 
sistent, drawing  up  of  the  legs,  and  in  boys  retraction  of  the 
scrotum.  The  abdomen  is  distended,  and  pressure  or  knead- 
ing usually  relieves  the  pain  and  quiets  the  child.  If  the 
gas  is  expelled  by  the  mouth  or  anus,  the  crying  usually 
ceases  at  once.  There  is  always  difficulty  in  getting  these 
children  asleep  and  in  keeping  them  so.  The  least  noise  or 
movement  disturbs  them.  They  will  usually  take  food  raven- 
ously, as  if  it  temporarily  relieved  them,  but  in  a  few  min- 
utes they  are  crying  again  with  pain. 

In  mild  cases  the  infant  is  simply  wakeful  and  fretful.  If 
severe,  there  may  be  prostration  and  cold  extremities.  Very 
many  infants  have  a  chronic  colic,  and  are  continually  crying 
and  very  restless. 

Diagnosis  :  This  is  usually  easy ;  but  we  must  never  forget 
the  possibility  of  some  grave  intestinal  disease  being  the 
cause  of  the  colicky  pain.  Appendicitis  and  intussusception, 
and  earache  especially,  must  be  excluded  before  calling  the 
case  a  simple  colic. 

Prognosis  :  This  is  good.  Prolonged  cases  can  be  cured  by 
proper  care  of  the  diet. 

Colic — treatment :  During  the  attack,  by  mouth  a  little 
brandy  and  hot  water,  or  ginger  and  hot  water,  or  hot  pep- 
permint-water, or  soda  and  hot  water,  will  assist  in  removing 
the  gas  from  the  stomach.  To  remove  the  intestinal  gases 
an  enema  of  warm  water  or  a  glycerin  suppository  is  most 
efficient.  Hot  applications  and  massage  to  the  abdomen  are 
very  soothing.  Opium  preparations  should  be  avoided  as 
much  as  possible. 


124  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

To  prevent  recurrence  of  the  colic  the  diet  should  be  in- 
vestigated and  any  errors  in  it  corrected.  If  any  one  of  the 
food-constituents  seems  at  fault,  reduce  its  quantity  in  the 
food.  If  all  the  constituents  seem  normal,  try  reducing  the 
total  quantity  of  food  given.     Cure  constipation  if  it  exists. 

CONSTIPATION. 

Constipation  is  one  of  the  most  frequent  disorders  of  in- 
fancy, and  one  of  great  difficulty  in  its  satisfactory  manage- 
ment. 

Etiology  :  The  causes  exist  either  in  the  child  or  in  its  food. 
Probably  the  latter  causes  are  the  more  important. 

Of  the  former,  feeble  muscular  power  in  the  intestinal  wall  is 
of  most  importance.  This  may  be  due  to  the  various  forms 
of  malnutrition,  of  which  rachitis  is  the  commonest.  In 
older  children,  lack  of  attention  to  the  desire  to  go  to  stool,  and 
of  the  formation  of  a  regular  habit,  is  a  prominent  cause. 
Decreased,  secretion  of  the  intestinal  fluids  and  of  the  bile 
is  probably  next  in  importance.  Certain  anatomical  peculiari- 
ties are  believed  to  play  their  part,  as  a  very  long  sigmoid 
flexure,  stricture  of  the  gut — congenital  or  acquired — kinks 
and  bends  from  adhesions,  tumors  inside  and  outside  the  gut, 
and  painful  fissures  at  the  anus,  producing  a  voluntary  con- 
stipation. 

Of  the  latter  class  a  deficiency  in  fat  is  probably  of  greatest 
importance.  This  occurs  in  babies  fed  on  the  breast  and  in 
those  fed  on  the  bottle.  Next  most  common  as  a  cause  is  the 
lack  of  enough  total  solids  in  the  food  to  leave  any  residue. 
Here  there  is  nothing  to  provoke  the  intestinal  peristalsis. 
Other  causes  are  ingestion  of  too  little  water,  or  excessive 
excretion  of  it  by  the  skin  or  kidneys,  leaving  the  faeces  dry. 
Prolonged  use  of  sterilized  milk  will  often  be  the  cause  of 
constipation,  as  a  return  to  fresh  milk  will  frequently  pro- 
duce regular  movements  again.  Drugs  given  for  other  causes, 
and  containing  opium  or  astringents,  are  factors  of  impor- 
tance. 

In  older  children  the  lack  of  a  proper  variety  to  the  diet, 
such  as  green  vegetables  and  fruit,  may  produce  constipation. 


CONSTIPA  TION.  125 

Constipation — symptoms :  The  local  symptoms  are  usually 
all  that  are  present.  Constipation  is  a  relative  term,  as  the 
normal  number  of  stools  per  day  varies  with  different  indi- 
viduals and  with  different  periods  of  life.  During  the  first 
year  less  than  two  stools  per  day  is  abnormal.  After  the 
first  year  the  passing  of  any  day  without  a  stool  is  abnormal. 
But  the  character  of  the  stool,  and  the  ease  or  difficulty  in 
its  discharge,  should  be  taken  into  consideration  as  well  as 
the  frequency. 

The  other  symptoms  associated  with  constipation  are  flatu- 
lence and  colic,  and  a  tendency  to  piles  and  to  hernia.  The 
hard  masses  of  faeces  may  irritate  the  rectum  and  anus,  and 
be  streaked  with  mucus  and  blood. 

Absorption  of  intestinal  toxins  may  produce  various  gen- 
eral symptoms,  as  headache,  languor,  disturbed  sleep,  and 
some  interference  with  nutrition.  The  tongue  is  furred,  the 
breath  is  foul,  and  anorexia  may  be  present. 

In  some  cases  the  hardened  fasces  may  block  up  and  irri- 
tate the  rectum  and  thus  set  up  a  false  diarrhoea,  the  fluid 
movements  taking  place  around  or  through  the  solid  masses, 
the  patient  presenting  the  signs  of  diarrhoea  while  really  suf- 
fering from  constipation. 

Prognosis  :  This  depends  on  the  cause  and  the  possibility 
of  its  removal.     Some  cases  are  very  stubborn  to  treatment. 

Constipation — treatment :  More  than  the  fact  of  the  existence 
of  constipation  must  be  known.  We  must  find  the  cause  of 
the  condition,  and,  if  possible,  the  part  of  the  intestine  at 
fault.  If  we  can  do  these,  we  can  treat  the  cases  far  more 
intelligently.  If  structural  or  pathological  conditions  are 
present,  such  that  we  cannot  remove  them,  we  must  content 
ourselves  by  treating  the  case  symptomatically. 

In  a  breast-fed  child  have  a  chemical  examination  of  the 
mother's  milk  made;  and  if  some  constituent  is  found  ab- 
normally low,  as,  for  instance,  the  fat,  take  measures  to  in- 
crease this.  In  bottle-fed  babies  modify  the  proportions  of 
the  milk-ingredients  by  adding  fat,  or  diminishing  the  pr<>- 
teids,  or  increasing  the  total  solids,  until  some  combination  is 
arrived  at  that  will  produce  daily  stools.  In  both  give  plain 
water   or  oatmeal-water  freely.     Cane-sugar  instead  of  lac- 


126  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

tose  will  at  times  assist,  and  maltose  will  often  do  better  yet. 
Stopping  the  sterilization  of  the  milk  may  also  aid. 

In  older  children  the  addition  of  fruit  and  green  vegeta- 
bles, as  orange-juice,  stewed  prunes,  baked  or  stewed  apples, 
is  of  value.  Massage  of  the  colon  and  along  its  course  will 
be  a  help  in  some  cases.  Muscular  exercise  is  of  value  by 
increasing  the  tone  of  all  the  muscles.  If  rachitis  or  mal- 
nutrition exist,  the  proper  treatment  should  be  undertaken 
for  the  cure  of  these. 

When  these  modifications  in  diet  and  improvements  in 
general  condition  fail  to  cure,  our  next  resort  is  to  specific 
treatment  of  the  constipation  itself.  There  are  three  general 
methods  for  this  :  suppositories,  enemata,  and  drugs.  If  the 
seat  of  the  constipation  is  in  the  rectum  only,  suppositories 
are  of  value.  Soap,  glycerin,  and  gluten  are  all  used,  and 
each  works  well ;  but  any  of  them,  if  too  long  continued,  may 
produce  rectal  irritation.  They  should  be  greased  before 
insertion. 

If  enemata  are  used,  plain  water,  or  soap-suds,  or  sweet 
oil,  or  glycerin,  may  be  injected.  They  produce  a  cleansing 
of  the  colon,  and  reflexly  excite  peristalsis  in  the  small  gut. 
It  is  best  to  use  small  quantities,  so  as  not  to  dilate  the  intes- 
tine too  much.  Their  effect  gradually  wears  off,  particu- 
larly if  too  large  quantities  of  fluid  are  used. 

Drugs  are  very  unsatisfactory  for  prolonged  use.  Calo- 
mel, castor  oil,  rhubarb,  cascara,  aloes,  and  phosphate  of  sodium 
are  the  best.  In  all  cases  attempt  to  form  a  regular  habit  of 
going  to  stool.  In  children  who  are  old  enough  to  be  taught 
this,  much  good  may  be  accomplished. 

INTESTINAL  OBSTRUCTION. 

This  means  a  mechanical  obstruction  to  the  passage  of  the 
contents  of  the  intestinal  canal.  The  varieties  of  the  obstruc- 
tion in  children  are  not  so  many  as  those  in  adults;  but 
almost  any  form  may  occur,  and  one  form  particularly  is 
a  disease  of  childhood.  The  forms  with  rare  causes  will  be 
mentioned,  while  the  important  variety — intussusception — 
will  be  described  in  detail. 


INTUSSUSCEPTION.  127 

Rarer  causes :  Foreign  bodies  may  be  the  cause  of  obstruc- 
tion. These  may  be  objects  swallowed,  as  solid  substances; 
or  masses  of  caked  drugs,  as  bismuth.  A  lump  of  lumbri- 
coid  worms  rolled  up  together  has  been  found  as  the  cause. 
Volvulus,  or  the  twisting  of  the  gut  upon  itself,  is  a  rare 
cause  in  children  ;  more  common  in  adults.  Strangulation, 
or  kinking  of  the  gut,  by  abnormal  bands  from  previous 
peritonitis ;  or  from  abnormal  openings  in  the  mesentery ;  or 
by  the  remains  of  Meckel's  diverticulum  ;  or  by  an  adherent 
appendix,  may  likewise  cause  strangulation.  Strangulated 
hernia  as  a  cause  of  obstruction  should  never  be  forgotten. 

INTUSSUSCEPTION. 

All  the  above  forms  of  obstruction  are  rare  in  childhood 
when  compared  with  this  condition. 

Definition  :  Intussusception,  or  invagination  of  the  intestine, 
consists  in  one  portion  of  the  bowel  passing  into  a  succeed- 
ing portion,  and  through  its  mechanical  presence  and  subse- 
quent swelling  and  bending  by  the  attached  mesentery,  block- 
ing up  the  lumen  of  the  bowel  and  causing  the  obstruction. 

Varieties :  Intussusceptions  may  occur  at  any  portion  of 
the  bowel,  but  are  commoner  in  certain  parts  than  in  others. 

The  commonest  location  is  for  the  apex  of  the  intussuscep- 
tum,  or  entering  portion,  to  be  formed  by  the  ileo-ccecal 
valve.  This  draws  in  after  it  the  colon,  and  is  called  the 
ileo-cceccd  variety. 

A  subvariety,  the  ileo-colic,  is  formed  by  the  invagination 
of  the  ileum  through  the  valve  and  into  the  colon,  but  without 
necessarily  invaginating  the  colon. 

The  enteric  variety  is  rarer,  and  consists  of  the  invagination 
of  some  part  of  the  small  gut  into  another  part. 

The  rarest  variety  of  all,  the  colic,  consists  of  the  invagi- 
nation of  some  part  of  the  colon  into  another  part. 

Intussusception  may  occur  in  two  places  at  once.  It  usu- 
ally takes  place  in  the  direction  of  the  peristalsis — that  is, 
downward  ;  but  the  reverse  may  occur  rarely. 

.Except  in  the  ileo-colic  variety,  the  apex  of  the  intnssus- 
ceptuni   is   fixed,  the  outer  sheaths,  or  intussuscipiens,  being 


128  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

gradually  infolded.  In  the  ordinary  variety  a  few  inches  to 
six  or  more  feet  of  bowel  may  be  involved. 

Mild  forms  of  intussusception  occur  frequently  just  after 
death.  They  are  usually  multiple  and  enteric,  always  short, 
and  usually  upward. 

Etiology  :  There  are  no  facts  of  any  value  in  causation.  It 
is  most  frequent  from  four  to  nine  months  of  age,  and  in 
males.  Most  cases  occur  in  previously  healthy  children. 
Previous  intestinal  disorder  is  present  in  a  small  proportion 
of  the  cases.  Irregular  peristaltic  action  of  the  intestinal 
walls  seems  the  exciting  cause. 

Intussusception — pathology  :  There  is  great  congestion  of 
the  invaginated  bowel ;  and  if  long  enough  continued,  this 
leads  to  gangrene  and  sloughing.  The  two  peritoneal  sur- 
faces in  contact  are  liable  to  form  adhesions  to  each  other, 
and  this,  combined  with  the  swelling  and  the  dragging  of  the 
mesentery,  makes  reduction  often  very  difficult.  If  adhe- 
sions form  and  the  intussusceptum  sloughs,  it  may  be  dis- 
charged entire  or  piecemeal  through  the  bowel,  and  sponta- 
neous cure  result.  If  adhesions  do  not  form,  the  sloughing 
leads  to  perforation  of  the  gut  and  infection  of  the  perito- 
neum. 

Intussusception — symptoms :  These  regularly  begin  sud- 
denly, with  severe  abdominal  pain.  It  is  located  in  the 
neighborhood  of  the  navel,  and  causes  the  child  great  agony. 
The  pain  is  paroxysmal  in  character,  and  is  almost  at  once 
accompanied  by  vomiting.  The  stomach  first  empties  itself 
of  its  contents,  and  afterward  ejects  bile  in  large  quantities ; 
later  the  vomiting  may  be  stercoraceous.  At  first  there  are 
one  or  two  loose  faecal  stools  ;  but  afterward  absolutely  no 
faecal  matter  is  passed,  but  only  bloody  mucus.  With  this  is 
marked  rectal  tenesmus.  Soon  after  the  attack  begins,  on 
palpating  the  abdomen  it  is  found  relaxed ;  and  usually  in  the 
neighborhood  of  the  transverse  or  descending  colon  a  tumor 
is  found.  In  a  fair  proportion  of  the  cases  rectal  examina- 
tion discloses  the  apex  of  the  advancing  intussusceptum.  In 
some  this  may  protrude  from  the  anus. 

As  the  case  advances,  tympanitic  distention  of  the  abdomen 
and  tenderness  develop.     At  first  there  is  no  fever.     If  in- 


INT  USS  USCEPTION.  129 

flarnmatory  signs  appear  in  the  intussusception,  it  may  de- 
velop. 

There  are  intense  prostration,  feeble  pulse,  cold  extremities, 
and  pallor.  A  marked  diminution  in  the  quantity  of  urine 
secreted,  or  complete  suppression,  is  frequently  present. 

There  are  chronic  cases  with  vague  abdominal  symptoms, 
but  without  complete  obstruction.  In  these  cases  the  pres- 
ence of  the  tumor  makes  the  diagnosis. 

In  the  acute  cases  the  disease  lasts  less  than  a  week.  Spon- 
taneous reduction  probably  occurs  at  times.  Spontaneous 
cure  by  adhesions  and  sloughing  may  occur.  Death  is  usually 
from  shock  ;  or,  if  shock  is  survived,  from  peritonitis. 

In  the  chronic  cases  the  duration  may  be  from  two  weeks 
to  a  month.  These  usually  die  from  exhaustion  or  the  de- 
velopment of  complications. 

Diagnosis :  With  a  typical  history,  and  a  careful  examina- 
tion showing  the  presence  of  a  tumor,  the  diagnosis  should 
be  easy.  Never  neglect  a  rectal  examination.  In  all  cases 
of  bloody  and  mucous  discharges  from  the  bowels  think  of 
intussusception  as  well  as  entero-colitis.  They  are  easy  to 
differentiate  if  both  are  in  mind.  In  chronic  cases  the  tumor 
is  the  diagnostic  point. 

Prognosis :  This  is  always  grave.  The  younger  the  child 
and  the  more  advanced  the  case  the  more  serious  is  the  prog- 
nosis. With  early  diagnosis  and  proper  treatment  many  re- 
cover. Spontaneous  recovery,  while  it  does  occur,  is  rare. 
Chronic  cases  seldom  recover. 

Intussusception — treatment :  As  soon  as  the  diagnosis  can 
be  made  adopt  energetic  methods  of  treatment.  Every 
hour's  delay  increases  the  dangers.  Give  absolutely  no  cathar- 
tics. These  only  increase  the  intestinal  peristalsis  and  drive 
the  intussusceptum  farther  in.  On  the  contrary,  keep  the 
patient  under  the  influence  of  opium.  This  fulfils  two  indi- 
cation.- ;  it  relieves  the  pain  and  decreases  the  peristalsis,  thus 
preventing  further  advance  of  the  invagination. 

Next,  an  attempt  should  at  once  be  made  to  reduce  the 
intussusception  by  means  of  mechanical  devices.  These  are 
inflation  by  air  and  injection  of  fluids.  Each  lias  its  advo- 
cates.    Either  is  bes<  done  under  an  anaesthetic. 

9—1).  C. 


130  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Inflation  is  performed  with  the  patient  on  his  back,  and 
the  air  is  pumped  into  the  bowel  through  a  rubber  rectal  tube 
attached  to  a  Davidson  syringe  or  to  a  small  hand-bellows. 
This  should  be  done  quite  slowly.  While  the  air  is  being  in- 
troduced the  abdomen  may  be  gently  massaged  upward  over 
the  tumor.  From  time  to  time  the  child  may  be  inverted  to 
aid  reduction  by  the  action  of  gravity.  The  amount  of  air 
introduced  should  be  governed  by  the  tension  of  the  abdomi- 
nal walls.  Sounds  or  physical  signs  may  suggest  reduction  ; 
but  to  be  sure  of  it  the  air  should  be  let  out  and  a  careful 
examination  for  the  disappearance  of  the  tumor  made.  After 
complete  reduction  the  symptoms  should  cease,  and  faecal 
movements  or  passage  of  gas  begin.  If  inflation  fails  the 
first  time,  it  may  be  repeated ;  but  more  than  two  trials  are 
useless. 

Injection  of  fluids  may  also  be  tried  to  reduce  the  intussus- 
ception. It  may  be  tried  first,  or  after  the  failure  of  in- 
flation. Again  the  child  is  anaesthetized,  and  a  warm  saline 
solution  is  introduced  into  the  bowel,  best  by  means  of  a  foun- 
tain-syringe having  an  elevation  of  four  to  six  feet.  The 
abdomen  may  be  massaged  during  the  introduction  of  the 
fluid,  and  inversion  may  also  be  tried.  A  bandage  rolled 
around  the  rectal  tube  prevents  escape  of  the  fluid.  The 
fluid  should  be  introduced  slowly,  with  interruptions,  and  the 
amount  will  vary  in  individual  cases.  It  is  more  difficult  to 
decide  whether  reduction  has  been  accomplished  in  these  cases 
than  when  using  air.  Again  the  fluid  must  be  let  out  and 
examination  made  for  the  tumor. 

If  reduction  is  accomplished  in  either  way,  the  child  must 
be  kept  quiet,  given  little  food,  and  held  under  the  influence 
of  opium  for  a  few  days,  until  the  danger  of  recurrence  has 
passed. 

Too  much  time  must  not  be  lost  in  trying  to  reduce  by  in- 
flation or  injection.  If  both  methods  fail — and  they  often 
will — resort  must  be  had  to  laparotomy,  as  otherwise  we  leave 
our  patient  to  almost  certain  death. 

It  is  best  to  be  prepared  for  operation  while  trying  the 
mechanical  devices  for  reduction  ;  and  if  they  fail,  operate 
before   the  patient   recovers  from   the  anaesthetic.     Of   late 


INTESTINAL   PARASITES— BOUND-WORMS.  131 

years  many  of  the  cases  operated  on  during  the  first  few  days, 
and  even  in  infants,  recover. 

In  chronic  cases  operative  results  are  quite  brilliant. 


INTESTINAL  PARASITES. 

Varieties  :  There  are  three  general  forms  of  worm  that  com- 
monlv  inhabit  the  intestines  of  children.  These  are  the 
round-worm,  ascarides  lumbricoides  ;  the  pin-worm,  oxyuris 
vermicularis  ;  and  two  varieties  of  tapeworm,  taenia  medio- 
canellata  and  taenia  solium. 

Worms,  however,  are  very  much  less  common  than  is  ordi- 
narily supposed  by  the  public  at  large.  The  life-history  of 
each  form  of  parasite  is  different,  and  as  each  requires  a 
special  treatment  a  separate  description  of  each  is  necessary. 


ROUND-WORMS. 

Description :  These  worms,  the  ascarides  lumbricoides,  are 
from  five  to  ten  inches  long,  the  female  being  the  longer. 
They  are  cylindrical-shaped,  taper  at  both  ends,  and  are  of  a 
pinkish-gray  color,  being  not  unlike  the  ordinary  angle-worm 
in  appearance.  The  worms  live  in  the  small  intestine,  and 
rarely  are  single.  Half  a  dozen  to  a  hundred  may  be  pres- 
ent. They  frequently  roll  up  into  large  masses.  They  have 
a  curious  tendency  to  wander  from  their  natural  home  in  the 
small  gut,  and  may  be  found  in  the  colon,  stomach,  oesopha- 
gus, and  even  in  the  nose  and  larynx.  At  times  they  escape 
into  the  peritoneal  cavity  through  an  intestinal  perforation. 
They  have  been  known  to  crawl  into  the  common  bile-duct 
and   to  block  it   up. 

The  eggs  arc  oval  in  shape,  and  about  T-J-g-  of  an  inch  long. 
The  contents  appear  granular,  and  the  coat  thick.  They  are 
discharged  in  large  numbers  in  the  stools,  and  have  great 
vitality  outside  the  body.  They  are  probably  swallowed  with 
the  food  or  drink,  and  after  entering  the  intestine  develop 
into  mature   worms  there. 

Round-worms — symptoms:   There  may  be   no  symptoms  at 


132  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

all,  and  the  finding  of  a  worm  in  a  stool  may  be  the  first 
suspicion  of  anything  being  wrong. 

In  other  cases  there  may  be  irregular  abdominal  pains  and 
tympanites,  with  restlessness,  poor  sleep,  grinding  of  the 
teeth,  and  picking  of  the  nose.  These  symptoms  are  all  more 
often  due  to  some  chronic  indigestion  than  to  the  presence  of 
the  worms.  Various  nervous  disturbances  of  an  emotional 
character  are  often  associated  with  the  presence  of  worms,  as 
headache,  dizziness,  hysterical  symptoms,  tetany,  and  even 
convulsions.  Certain  mechanical  symptoms  may  be  trouble- 
some, as  the  massing  of  large  numbers  of  the  worms  in  a  ball 
somewhere  in  the  intestine ;  or  due  to  their  tendency  to  travel 
into  undesirable  situations. 

Diagnosis :  No  symptoms  or  set  of  symptoms  can  be  relied 
on  for  a  diagnosis.  The  only  positive  sign  is  by  seeing  the 
worms  or  their  eggs  in  the  stools.  If  one  worm  is  found,  the 
probability  of  others  being  present  is  strong. 

Round-worms — treatment :  The  drug  of  most  value  for  kill- 
ing or  benumbing  the  ascarides  is  santonin.  This  is  best 
given  after  a  few  hours  of  fasting,  and  must  be  accompanied 
or  followed  by  a  cathartic,  as  in  itself  it  does  not  remove  the 
worms.  It  is  well  given  rubbed  up  with  calomel,  and  in 
divided  doses.  The  dose  for  a  child  of  five  years  is  two  to 
four  grains.  A  dose  of  castor  oil  may  be  given  afterward, 
if  the  calomel  does  not  completely  empty  the  canal. 

PIN-WORMS. 

Description :  These  are  very  small  worms,  called  also 
thread-  and  seat-worms.  The  technical  name  is  oxyuris  ver- 
micularis.  They  are  of  about  the  diameter  of  thread  or  a  pin, 
and  are  from  one-sixth  to  one-third  of  an  inch  long,  the 
female  again  being  the  longer.  They  are  white  in  color,  and 
taper  to  a  point  at  the  tail.  The  eggs  are  oval  and  small, 
with  a  thin  coat.  The  worms  live  almost  entirely  in  the 
rectum  and  colon,  and  are  present  in  enormous  numbers. 
They  are  propagated  by  the  swallowing  of  the  ova.  The 
worms,  and  also  the  eggs,  are  passed  in  large  numbers  with 
the  stools.     They  are  frequently  found  alive  in  the  folds  of 


PIN-WORMS.  133 

skin  around  the  anus  and  genitals,  and  these  act  as  a  frequent 
source  of  reinfection  to  the  patient. 

Pin-worms — -symptoms :  The  most  important  sign  of  the 
presence  of  the  oxyuris  is  intense  itching  of  the  anus  and 
genitals.  This  is  usually  worse  when  the  child  goes  to  bed. 
The  scratching  for  relief  may  lead  to  eczema  of  the  anus,  or 
balanitis,  or  vulvitis.  Masturbation  and  incontinence  of 
urine  are  frequent  results. 

The  child's  sleep  is  disturbed,  and  he  becomes  restless  and 
wakeful.  The  worms  irritate  the  colon,  and  much  mucus  is 
usually  discharged  with  the  stools.  Reflex  nervous  symp- 
toms are  much  rarer  than  with  the  other  varieties  of  worms. 

Diagnosis:  Itching  of  the  anus  and  genitals  in  children 
should  always  make  us  suspect  seat-worms,  but  the  only  posi- 
tive diagnosis  again  rests  on  seeing  the  worms  themselves  or 
their  ova.  Examine  the  discharges  and  also  the  parts  about 
the  anus  very  carefully  for  either. 

Pin-worms — treatment :  Scrupulous  cleanliness  of  the  pa- 
tient is  the  first  thing  of  importance.  He  should  be  kept 
very  clean,  and  his  hands  and  the  parts  about  the  anus  should 
be  washed  daily  with  some  antiseptic  solution,  as  the  bichlo- 
ride of  mercury  1  :  5000.  The  anus  should  be  kept  anointed 
with  a  2  per  cent,  carbolic  salve,  to  prevent  itching  and  to 
kill  any  worms  that  emerge  from  the  rectum. 

By  mouth,  salts  should  be  given  to  produce  watery  move- 
ments and  to  wash  the  worms  that  are  high  up  in  the  bowel 
down  into  the  colon. 

Once  a  day  the  colon  should  be  washed  out  thoroughly  with 
a  large  quantity  of  water  passed  through  a  long  rectal  tube. 
This  water  should  contain  either  soapsuds,  or  quassia,  or 
alum,  or  salt.  Bichloride  of  mercury,  in  1  :  10,000  or 
1  :  20,000  solution,  is  very  useful  for  killing  the  worms;  but 
there  is  danger  of  poisoning  from  some  of  the  solution  being 
lefl   behind. 

The  cure  is  slow,  but,  by  persistent  use  of  the  above  means 
over  some  length  of  time,  can  be  effected.  The  clothing,  toys, 
bedding,  and  even  carpets  should  be  thoroughly  cleaned  for 
fear  of  reinfect  ion. 


134  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


TAPEWORMS. 

Description :  Tapeworms  are  from  twenty  to  fifty  feet  long, 
of  a  white  color,  and  composed  of  many  flat  segments.  The 
segments  are  fairly  uniform  in  size,  but  taper  gradually  to  the 
head,  where  the  newly  formed  segments  develop.  The  head 
is  a  modified  segment,  the  size  of  a  pin's  head,  and  contains 
suckers  by  which  the  worm  fastens  itself  to  the  gut. 

Varieties  :  The  commonest  varieties  of  tapeworm  found  in 
this  country  are  two,  the  beef  tapeworm,  or  icenia  mediocanel- 
lata,  and  the  pork  tapeworm,  or  tcenia  solium.  Each  segment 
of  each  variety  is  a  sexually  mature  individual,  and  ova  are 
cast  off  continually  by  them.  Segments  from  the  tail  end 
are  also  broken  off  from  time  to  time  and  discharged  from 
the  bowel.  New  segments  grow  from  the  head-end  to  take 
their  place. 

Cysticercus :  The  eggs  from  the  tapeworm  are  swallowed 
by  animals  in  their  food,  and  passing  into  their  stomachs  the 
embryos  are  set  free  and  are  carried  by  the  blood  around  the 
body  and  are  deposited  in  various  parts  of  the  tissues,  among 
others  the  muscles.  Arrived  here  they  form  a  little  wall 
around  themselves  and  take  on  a  larval  condition.  They  are 
then  called  cysticerci,  and  may  live  in  this  condition  for  some 
years.     Each  cysticercus  is  about  the  size  of  a  pea. 

When  the  flesh  of  these  animals  is  eaten  by  a  human  being, 
unless  the  cysticercus  is  destroyed  by  the  heat  of  cooking,  it 
is  set  free  in  the  digestive  tract,  and  attaches  itself  to  the 
mucous  membrane  of  the  small  intestine  and  grows  there 
into  an  adult  tapeworm. 

Habitat :  The  toznia  mediocanellata  lives  in  the  bodies  of 
cattle  during  its  larval  state,  and  hence  is  called  the  beef  tape- 
worm. The  tcenia  solium  lives  during  its  larval  state  in  the 
bodies  of  hogs,  and  hence  is  called  the  pork  tapeworm.  More 
than  one  taenia  mediocanellata  is  frequently  found  in  a  patient 
at  a  time  ;  but  the  tsenia  solium,  as  its  name  implies,  is  usually 
single. 

Tapeworms — symptoms  :  There  may  be  no  symptoms  at  all, 
the  finding  of  segments  in  the  stool  being  the  first  intimation 
of  the  presence  of  the  worm.     Irregular  pains  in  the  abdo- 


PRURITUS  ANI.  135 

men,  large  appetite,  restlessness,  and  picking  at  the  nose  are 
observed  in  some  cases.  There  may  be  diarrhoea.  Probably 
these  symptoms  are  all  due  more  to  disordered  digestion  than 
to  the  worm. 

Tapeworms — diagnosis :  This  is  made  entirely  by  finding 
segments  of  the  worms  in  the  stools.  The  physician  should 
always  examine  these  segments  himself. 

Tapeworms — treatment :  Preventive  treatment  consists  in 
not  eating  underdone  beef,  or  pork,  or  pork  preparations. 
Thorough  cooking  will  destroy  the  cysticerci. 

If  the  presence  of  the  worm  is  proven,  treatment  should 
be  begun  at  once  by  first  starving  the  patient  for  some  time. 
To  increase  this  time  the  night  may  be  taken  advantage  of 
in  children.  Have  the  child  go  to  bed  with  a  very  light  meal 
and  a  laxative.  In  the  morning,  after  the  stool  (which  may 
be  assisted  by  an  enema)  and  without  any  breakfast,  give  the 
specific  drug.  Follow  this  in  an  hour  by  a  thorough  purge, 
the  best  of  which  is  a  tablespoonful  of  castor  oil. 

Practically  only  two  drugs  need  to  be  remembered  as 
tamiacides,  male-fern  and  pomegranate.  The  first  is  given  as 
oleoresina  aspidii,  in  doses  of  half  a  drachm  to  one  drachm,  and 
made  up  in  an  emulsion  with  syrups,  or  in  capsules,  if  these 
can  be  swallowed.  It  makes  a  nasty  mixture,  however,  and 
in  cases  where  expense  need  not  be  taken  into  account 
Tanret's  pelletierine,  made  from  the  alkaloid  of  the  pome- 
granate, is  the  nicest  way  of  attacking  the  worm.  Each 
bottle  contains  an  adult  dose.  For  a  child  a  proportionate 
amount  should  be  given.  It  also  should  be  followed  by  a 
purge  in  an  hour.  To  insure  against  recurrence  the  head 
must  be  removed. 

DISEASES  OF  THE  ANUS  AND  RECTUM. 

PRURITUS  ANI. 

Pruritus  ani  is  at  times  seen  in  children,  and  is  an  intense 
itching  in  the  neighborhood  of  the  anus. 

Etiology:  The  itching  may  be  due  to  pin-worms  in  the 
rectum,  to  pedieuli,  to   irritating   Cecal   discharges,  to   consti- 


136  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

pation,  or  to  eczema  of  the  anus.  The  constant  scratching 
tends  to  make  it  worse  by  setting  up  an  artificial  dermatitis. 
Treatment :  If  possible  find  the  cause  and  remove  it. 
Keep  the  parts  absolutely  clean  by  bathing  them  after  every 
stool.  After  bathing  anoint  the  anus  with  some  such  oint- 
ment as, 

Tfy.  Acid,  carbolic V([x. 

Ung.  zinc,  oxid 3j. 

PROLAPSUS  ANI. 

Varieties  :  There  are  two  varieties  of  this  condition  :  1, 
Where  a  portion  of  the  mucous  coat  only  of  the  rectum  is 
prolapsed  ;  and  2,  where  the  entire  rectal  wall  is  invaginated 
through  the  sphincter. 

Etiology :  This  condition  is  quite  common  in  children  in 
the  second  and  third  years.  It  is  predisposed  to  by  the  ana- 
tomical fact  of  the  very  loose  attachment  of  the  submucous 
connective  tissue  of  the  rectum. 

Chronic  intestinal  disorders  and  constipation,  by  causing 
straining  efforts  at  stool,  are  the  common  exciting  causes. 
Phimosis,  vesical  calculus,  and  rectal  polypus  may  be  causa- 
tive agents. 

Prolapsus  ani — symptoms :  The  characteristic  symptom  is 
the  appearance  during  stool  of  a  dark-red  or  purplish-colored 
tumor  protruding  from  the  anus.  This  is  covered  by  mucous 
membrane,  which  may  be  in  a  condition  of  acute  inflamma- 
tion. It  may  bleed  freely.  The  mass  often  will  return  spon- 
taneously, or  may  be  easily  reduced.  There  is  no  pain  con- 
nected with  the  protrusion.  After  prolapsing  once,  recurrence 
with  each  stool  is  common. 

Diagnosis :  This  condition  must  be  differentiated  from 
haemorrhoids  and  rectal  polypi.  After  reduction  the  absence 
of  any  tumor  on  rectal  examination  excludes  these  conditions. 
More  important  is  to  diagnose  it  from  intussusception,  in 
which  the  presence  of  pain  and  obstruction  are  of  most 
value. 

Prolapsus  ani — treatment :  Lay  the  child  on  its  face,  and, 
having  oiled   the  mass,  gentle   pressure  will   usually  easily 


HEMORRHOIDS— FISSURA   ANI.  137 

reduce  it.  If  difficulty  is  found,  the  application  of  cold  or 
the  use  of  an  anaesthetic  may  be  called  for.  After  reduction 
keep  the  child  on  its  back  for  an  hour  to  prevent  recurrence, 
and  before  allowing  it  to  move  about  a  pad  to  the  anus  held 
in  place  by  a  T-bandage  should  be  applied.  After  this  the 
child  should  not  be  allowed  to  defecate  in  the  ordinary  sitting 
posture.  He  should  be  made  to  lie  down  on  his  back  or  side, 
and  to  use  a  bedpan.  The  bowels  should  be  kept  open  by 
the  use  of  laxatives.  Any  of  the  causes  of  the  condition  that 
may  be  present  should  be  removed.  A  daily  enema  of  some 
astringent  solution,  as  alum  or  tannin,  tends  to  contract  the 
mucous  membrane  and  to  prevent  recurrence. 

If  these  simple  means  fail,  linear  cauterization  by  nitric 
acid,  made  under  an  anaesthetic  and  followed  by  artificial  con- 
stipation with  opium  for  a  few  days  will  usually  cure  the 
cases  permanently.  The  actual  cautery  may  be  used  instead 
of  nitric  acid. 

HEMORRHOIDS. 

Definition  :  These  are  vascular  tumors  growing  in  the  lower 
portion  of  the  rectum,  outside  or  inside  the  sphincter,  from 
dilatation  of  the  bloodvessels  of  the  part.  They  are  quite 
rare  in  childhood,  and  when  they  do  exist  are  generally  of 
the  external  variety. 

Etiology :   Chronic  constipation. 

Symptoms :  Presence  of  the  vascular  masses  around  the 
anus,  and   pain   at  stool.     Bleeding  is   rare   in  children. 

Haemorrhoids — treatment :  Regulate  the  bowels.  Some 
astringent  ointment,  as  the  unguentum  galhe,  may  be  used 
locally.  Operative  interference  is  rarely  required  ;  but,  if 
necessary,  ligation  is  probably  the  best  procedure. 


FISSURA  ANI. 

In  fissura  ani  a  small  ulcer  is  present  at  the  anal  margin, 
and  usually  extends  over  the  area  that  is  under  the  action  of 
the  sphincter.     It  is  a  fairly  common  affection  of  childhood, 

and  is  seen  at  times  even  in  infant-. 

Etiology:   The  passage  of  hardened  f;eces,  scratching  to  re- 


138  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

lieve  pruritus,  or  traumatism  from  the  nozzle  of  a  syringe 
may  cause  the  fissure. 

Symptoms :  Pain  at  and  after  stool  is  the  marked  symp- 
tom of  this  condition.  On  examination,  an  ulcer  with  its 
long  diameter  parallel  with  the  long  axis  of  the  bowel,  and 
lying  over  the  sphincter,  will  be  seen.  It  has  a  grayish  base, 
and  often  bleeds  slightly. 

Fissura  ani — treatment :  Clean  the  parts  and  touch  the  base 
of  the  ulcer  with  silver  nitrate  stick.  Keep  the  bowels  open. 
If  healing  does  not  take  place  under  this  method,  stretch  the 
sphincter  and  keep  the  parts  at  rest,  when  cure  will  be  rapid. 

ISCHIORECTAL  ABSCESS. 

Definition :  This  is  a  collection  of  pus  in  the  cellular  tissue 
around  the  lower  portion  of  the  rectum. 

Etiology :  Traumatism  is  an  active  cause.  It  may  arise 
through  infection  of  the  cellular  tissue  from  the  rectum 
through  either  the  lymph-  or  bloodvessels. 

Symptoms  :  A  sense  of  fulness,  intense  and  throbbing  pain, 
and  tenderness  of  the  parts  are  the  significant  symptoms. 
Defecation  causes  great  agony.  Some  fever  with  its  con- 
stitutional symptoms  is  usually  present. 

On  examination,  a  tense,  red,  tender  swelling  will  be  found 
on  one  or  the  other  side  of  the  anus.  Fluctuation  may  be 
obtained  from  the  skin  surface  or  from  the  rectum. 

Ischio- rectal  abscess — treatment :  Early  and  prompt  incision 
through  the  skin,  in  a  line  radiating  from  the  anus,  should  be 
made.  The  finger  should  be  inserted  in  the  wound,  and  any 
partitions  broken  down.  The  wound  should  be  irrigated  and 
packed  to  heal  by  granulation. 

FISTULA  IN  ANO. 

Fistula  in  ano  is  an  unhealed  ischio-rectal  abscess.  The 
sinus  may  lead  from  the  rectum  to  the  old  abscess-cavity,  or 
from  the  skin  to  the  old  abscess  cavity,  or  be  complete  and 
lead  from  the  rectum  through  the  old  abscess-cavity  to  the 
skin -surface. 


ACUTE  PROCTITIS.  139 

Etiology :  There  may  be  a  history  of  an  acute  ischio-rectal 
abscess  which  has  been  untreated ;  or  the  fistula  may  result 
without  au  attack  of  precedent  acute  and  painful  inflamma- 
tion. These  chronic  cases  are  more  likely  to  be  of  a  tuber- 
cular nature. 

Symptoms:  There  is  no  special  pain  in  this  condition,  but 
the  sign  of  suspicion  is  a  discharge  of  pus  or  bloody  fluid 
with  the  stools,  through  either  the  external  or  the  internal 
opening.  On  examination,  the  opening  will  be  found  either  on 
the  skin-surface  or  in  the  rectal  wall ;  if  complete,  a  probe  can 
be  passed  through  the  fistula,  or  colored  fluid  or  peroxide 
of  hydrogen  can  be  syringed  through  to  locate  the  internal 
opening. 

Treatment:  Any  variety  of  incomplete  fistula  should  first 
be  made  complete,  by  passing  a  director  through  from  the 
skin-opening  (an  artificial  one  being  made  if  necessary)  into 
the  rectum,  and  then  bringing  the  point  of  the  director  out 
through  the  anus.  Along  this  as  a  guide,  cut  through  the 
intervening  tissue,  dividing  the  sphincter  once  only.  If 
pockets  exist,  open  into  them  freely  from  the  first  incision. 
Curette  the  tissue,  pack  with  gauze,  and  let  the  wound  heal 
by  granulation. 

ACUTE  PROCTITIS. 

"Proctitis"  is  applied  to  an  inflammation  of  the  rectum 
unaccompanied  by  inflammatory  trouble  higher  up  in  the 
bowel . 

Etiology :  Enemata,  suppositories,  traumatism  from  the 
nozzle  of  a  syringe,  thread-worms,  and  irritation  from  hard- 
ened feces  are  frequent  causes.  The  inflammation  may  be 
due  to  infection  by  the  germs  of  gonorrhoea,  diphtheria,  or 
scarlet  fever. 

Pathology:  The  rectum  may  be  the  seat  of  a  simple  catar- 
rhal inflammation  ;  or  superficial  or  deep  ulcers  may  form  ; 
or  there  may  be  an  inflammation  with  the  production  of  a 
false  membrane. 

Acute  proctitis — symptoms:  There  are  mild  constitutional 
symptoms   only,  the    local   signs   being  the  most   important. 


140  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

There  are  marked  rectal  tenesmus,  and  the  frequent  passage 
of  very  small  stools  each  containing  a  large  proportion  of 
mucus  and  some  blood.  Prolapsus  ani  is  a  frequent  compli- 
cation. Pruritus  ani  and  excoriations  of  the  neighboring 
skin  are  common.  In  ulcerative  cases  there  are  pus  in  the 
stools  and  marked  pain. 

Acute  proctitis — treatment :  The  patient  should  be  put  to 
bed,  and  on  a  proteid  diet.  The  bowels  should  be  moved  by 
small  doses  of  castor  oil.  Daily  injections  of  some  bland 
fluid  should  be  employed  to  wash  out  the  rectum  and  quiet 
the  tenesmus.  Starch-water  and  laudanum  is  a  useful  wash. 
Suppositories  of  opium  or  of  cocaine  may  be  used.  If 
ulcers  are  present  and  can  be  seen,  a  solution  of  boric  acid  or 
nitrate  of  silver  should  be  used  as  a  local  application.  If  any 
removable  cause  is  present,  it  should  be  attended  to. 

POLYPUS  RECTI. 

Polypus  is  a  much  commoner  condition  in  childhood  than 
in  adult  life.     No  cause  for  the  growth  is  known. 

Pathology :  The  polyp  is  a  pedunculated  body  about  the 
size  of  a  hazelnut.  Histologically  it  is  of  a  myxo-fibroma- 
tous  or  adenomatous  structure.  There  may  be  only  one,  or 
many  tumors.  In  the  early  stages  they  may  be  sessile,  but 
in  time  they  always  tend  to  become  pedunculated.  They  are 
usually  located  in  the  lower  segment  of  the  rectum. 

Polypus  recti — symptoms  :  The  symptoms  are  bleeding  from 
the  rectum,  associated  with  some  rectal  irritation  and  tenes- 
mus. They  may  lead  to  a  mucous  discharge  and  to  prolapsus 
ani.  As  the  pedicle  grows  long  enough  the  tumor  is  often 
protruded  during  stool. 

On  examination  it  appears  the  color  of  mucous  membrane  ; 
but  if  protruded  and  pinched,  it  has  a  purplish  tint.  It  is 
found  to  be  distinct  from,  but  attached  to,  the  general  mucous 
membrane,  thus  differentiating  it  from  prolapsus  ani. 

Polypus  recti — treatment :  This  consists  in  tying  the  pedicle 
off  at  its  attachment,  and  cutting  the  tumor  away  beyond  the 
ligature.  If  more  than  one  polyp  exist,  each  must  be  treated 
the  same. 


JAUNDICE.  141 

DISEASES  OF  THE  LIVER. 

The  liver  in  new-born  babies  and  in  early  childhood  is,  pro- 
portionately to  the  body-weight,  a  larger  organ  than  in  adults. 
This  should  be  remembered  in  estimating  its  size,  as  it  will 
be  found  normally  extending  below  the  free  border  of  the 
ribs.  This  comparatively  large  size  has  some  relation  to  the 
direct  connection  of  the  liver  with  the  placental  circulation. 

Notwithstanding  the  large  size  of  the  gland,  diseases  of  the 
liver  in  infancy  and  childhood  are  comparatively  rare,  and 
clinically  the  liver  offers  little  of  interest. 

JAUNDICE. 

Definition :  Icterus  neonatorum,  the  jaundice  of  early 
infancy,  has  already  been  described.  This  is  a  jaundice  due 
to  changes  in  the  blood,  hematogenous  so  called. 

Jaundice  due  to  changes  in  the  liver,  hepatogenous,  does, 
however,  occur  in  children.  It  is  also  called  simple  and 
catarrhal  jaundice.  Under  the  term  gastro-duodenitis  an 
intense  and  more  widespread  form  of  the  disease  is  recog- 
nized. There  may,  however,  be  only  a  catarrhal  inflamma- 
tion of  the  bile-ducts  present,  and  no  involvement  of  the 
duodenum  or  stomach.     This  is  the  form  under  consideration. 

Jaundice — etiology :  The  mucous  membrane  of  the  com- 
mon or  hepatic  ducts  is  swollen,  thus  closing  the  lumen  of 
these  ducts.  A  plug  of  inspissated  bile,  a  round-worm,  or 
rarely  a  gall-stone  may  plug  the  duct.  Errors  in  diet  or 
exposure  to  cold  may  be  the  causative  agent.  In  many  cases 
there  seems  no  exciting  cause. 

Symptoms :  The  main  sign  of  simple  jaundice,  and  often 
the  only  one,  is  the  yellow  discoloration  of  the  skin  and 
mucous  membranes.  It  varies  from  a  quite  pale  lemon  tint 
to  a  decided  dark-yellow  color.  The  urine  is  dark  brown, 
and  contains  bile-pigment  in  abundance.  The  stools  are 
white  or  "clay-colored,"  due  to  the  absence  of  bile  from  the 
intestinal  tract.  The  pulse  is  often  slowed,  and  there  may  be 
itching  of  the  skin,  particularly  if  the  jaundice  lias  been 
persistent.  Urticaria  may  be  present.  The  bowels  are  apt 
to  be  constipated. 


142  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Physical  signs :  On  examination  the  liver  is  usually  a 
little  enlarged,  and  some  tenderness  over  it  is  present.  The 
gall-bladder  may  be  found  distended. 

Prognosis  :  This  is  good,  as  most  of  the  cases  recover  rather 
rapidly,  even  if  left  alone.  The  duration  is  one  or  two  weeks. 
When  the  common  duct  is  plugged  by  a  round-worm  or 
other  solid  body  the  prognosis  is  not  so  good. 

Jaundice — treatment :  The  diet  should  be  free  from  fats  and 
sugars.  The  bowels  should  be  kept  open  by  calomel,  or 
salines,  or  aloes.  Phosphate  of  sodium  is  one  of  the  best 
drugs  to  use  with  children,  owing  to  its  lack  of  taste.  An 
excess  of  water  should  be  given  to  drink.  Large  enemata  of 
cold  water  have  been  found  quite  useful  in  the  more  obstinate 
cases. 

FUNCTIONAL  DISORDERS  OF  THE  LIVER. 

Functional  disorders  of  the  liver  are  most  apt  to  be  asso- 
ciated with  disturbances  of  the  functions  of  the  stomach  and 
intestines,  but  at  times  the  liver  alone  may  be  involved. 

Either  the  bile-producing  function  of  the  liver  may  be  dis- 
turbed, or  the  chemical  changes  which  should  normally  take 
place  in  the  blood  passing  through  the  liver  are  imperfectly 
performed. 

While  this  whole  question  is  as  yet  in  an  unsettled  state  as 
regards  exact  knowledge,  still  much  of  the  evidence  points  to 
disorders  of  the  liver  functions  as  being  the  basis  of  condi- 
tions which  are  variously  styled,  lithsemia,  biliousness,  uric- 
acid  diathesis,  and  so  on.  Such  conditions  are  fairly  common 
in  childhood,  although  they  are  undoubtedly  often  overlooked 
and  ascribed  to  other  causes. 

Etiology :  Heredity  seems  to  be  the  main  predisposing  cause. 
The  exciting  cause  is  the  habitual  eating  of  improper  food, 
or  of  too  large  quantities  of  food  ;  and  insufficient  muscular 
exercise. 

Functional  disorders  of  the  liver — symptoms :  Constipation, 
flatulence,  headaches,  bad  breath,  coated  tongue,  poor  nutri- 
tion, and  ansemia  are  the  most  marked  symptoms.  The  ap- 
petite is  apt  to  be  capricious.     The  fseces  are  light  colored 


ACUTE  AND   CHRONIC  CONGESTION  OF  THE  LIVER.     143 

and  have  an  offensive  odor.  The  urine  is  of  high  specific 
gravity,  and  contains  an  excess  of  urates  or  phosphates. 

These  children  are  apt  to  be  neurotic,  and  irritable,  and  to 
have  frequent  regular  or  irregular  nervous  "  explosions  "  of 
various  sorts.     These  frequently  develop  at  puberty. 

Functional  disorders  of  the  liver — treatment :  This  is  fairly 
successful  where  the  family  compel  the  child  to  carry  out  the 
physician's  directions. 

In  the  first  place,  the  diet  should  be  regulated.  Sugars 
and  fats  should  be  avoided.  An  easily  digested,  mixed  diet, 
given  at  regular  intervals,  and  in  not  excessive  quantities  at 
a  time,  should  be  prescribed.  Plenty  of  water  should  be 
given  daily  to  keep  the  various  fluids  of  the  body  dilute. 
Regular  outdoor  exercise  should  be  enforced. 

As  drugs,  those  that  increase  the  production  of  bile  are 
indicated,  phosphate  of  sodium,  aloes,  podophyllin,  and  rhu- 
barb. After  a  course  of  such  treatment  extended  over  a 
considerable  time  the  tendency  to  outbreaks  of  these  disor- 
ders can  usually  be  overcome. 

ACUTE  CONGESTION  OF  THE  LIVER. 

Varieties  :  The  liver  may  be  congested  either  actively  or 
passively.  The  acute  congestions  are  much  rarer  than  the 
chronic. 

Etiology :  It  is  the  result  of  poisoning  by  malaria  or  phos- 
phorus ;  may  follow  overeating  of  rich  foods  ;  and  be  a  com- 
plication of  simple  jaundice  or  gastro-duodenitis. 

Symptoms  :  These  are  very  slight.  Moderate  jaundice  may 
be  present.  The  liver  is  moderately  and  uniformly  enlarged, 
and  may  be  slightly  tender  to  pressure. 

Acute    congestion  of    the    liver — treatment :    This   consists 

simply  in  removing  the  cause,  or  rather  in  treating  the  Cott- 
le   ••      «  .  ~      ,  O 

dition  giving  rise  to  the  congestion. 

CHRONIC  CONGESTION  OF  THE  LIVER. 

Etiology:  This  is  the  commoner  variety  of  congested  liver. 
It  is  never  a  primary  disease,  but  is  always  secondary  to  con- 
ditions causing  stasis  of  the  blood-current.     The  commonest 


144  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

cause  is  congenital  or  acquired  heart-disease,  and,  next  to  this, 
chronic  pulmonary  conditions,  as  emphysema,  pleurisy,  or  in- 
terstitial pneumonia. 

Pathology :  The  liver  is  enlarged,  firm  on  pressure,  and 
harder  to  cut  than  normal.  The  surface  is  dark,  and  on  sec- 
tion the  so-called  nutmeg  appearance  is  present,  due  to  the 
dilatation  of  the  central  veins  of  the  lobules.  There  is  some 
increase  in  the  connective  tissue. 

Chronic  congestion  of  the  liver — symptoms :  These  are  due 
rather  to  the  primary  disease  than  to  the  congested  liver. 
There  may  be  some  slight  jaundice  and  other  symptoms  in- 
dicative of  interference  with  the  functions  of  the  liver,  such 
as  coated  tongue,  poor  appetite,  and  constipation. 

On  examination  the  lower  edge  of  the  liver  is  found  to 
reach  well  below  the  costal  border,  and  to  be  easily  felt  by 
palpation.  The  enlargement  will  be  found  uniform,  and  there 
will  be  no  nodules. 

Diagnosis  :  This  should  be  made  from  hypertrophic  cirrho- 
sis and  from  the  enlarged  liver  of  leukaemia.  The  presence 
of  the  causative  factor  is  of  special  value  in  congestion. 

Prognosis  :  This  depends  entirely  on  the  importance  of  the 
primary  disease. 

Chronic  congestion  of  the  liver — treatment :  The  removal  or 
treatment  of  the  cause  is  the  rational  method  of  caring  for 
this  disease.  The  occasional  use  of  a  saline  laxative  tends 
temporarily  to  reduce  the  congestion. 

SUPPURATIVE  HEPATITIS. 

Varieties  :  There  are  two  varieties  of  this  condition  in  chil- 
dren, as  in  adults.  In  one  there  is  a  single  circumscribed 
abscess;  in  the  other  there  are  multiple  points  of  suppuration. 
Either  form  is  rare  in  children. 

Etiology  :  Traumatism  seems  to  have  been  present  in  many 
of  the  cases.  Dysentery  occasionally  precedes  the  abscess. 
A  suppurative  inflammation  of  the  portal  veins  is  more  com- 
monly found  as  a  cause.  This  may  arise  from  the  umbilicus, 
from  the  appendix,  or  from  typhoid  ulcers.  It  may  be  a  meta- 
static pyaemic  abscess.     In  many  cases  no  cause  can  be  found. 


FATTY  LIVER.  145 

Suppurative  hepatitis — symptoms  :  In  the  variety  with  mul- 
tiple suppurative  points  we  usually  have  the  preceding  symp- 
toms of  the  inflammation,  in  the  area  drained  by  the  portal 
veins,  which  is  the  cause  of  the  hepatitis. 

The  signs  pointing  to  involvement  of  the  liver  are  enlarge- 
ment, pain,  and  tenderness  over  that  organ.  More  or  less 
jaundice  usually  develops  coincidently.  Chills  and  irregular 
fever  are  present.  After  a  time  the  typhoid  state  develops, 
with  low  muttering  delirium,  stupor,  dry,  brown  tongue,  and 
sordes  on  the  lips  and  teeth.  Diarrhoea  soon  begins,  with 
thin,  offensive,  light-colored  stools.  The  urine  contains  bile- 
pigment,  and  later  albumin  and  casts.  Rapid  emaciation  is 
regularly  seen. 

In  the  variety  with  single  abscess  the  symptoms  are  less 
acute.  There  are  pain  in  the  region  of  the  loins,  chills, 
sweating,  irregular  fever,  loss  of  flesh  and  strength,  and  some 
jaundice.     The  typhoid  state  develops  less  rapidly. 

There  are  cases  where  the  symptoms  are  entirely  latent, 
and  the  abscess  is  discovered  by  accident. 

On  examination  the  liver  is  tender  and  enlarged,  and  fre- 
quently the  enlargement  is  irregular,  the  abscess  being  near 
the  surface  and  pointing  above  or  below. 

Diagnosis :  The  presence  of  hepatic  symptoms,  combined 
with  irregular  chills  and  fever,  and  a  uniform  or  irregular 
enlargement  of  the  liver,  are  the  points  for  diagnosis. 

Withdrawal  of  pus  through  an  exploring-needle,  is  the 
only  positive  evidence  of  abscess  that  we  have.  Failure  to 
obtain  pus  on  the  first  trial  does  not  exclude  its  presence. 

Prognosis:  In  multiple  abscesses  the  prognosis  is  almost 
surely  fatal.  In  the  single  variety,  although  still  grave,  it  is 
somewhat  better. 

Suppurative  hepatitis — treatment :  This  is  purely  surgical. 
II*  the  pus  is  so  situated  that  it  can  be  reached  and  freely 
evacuated,  a  good  many  cases  will  recover. 

FATTY  LIVER. 

This  condition  is  a  fatty  degeneration  of  the  hepatic  cells, 
and  is,  as  ;i  rule,  secondary  to  some  of  the  wasting  diseases  of 

10—1).  r. 


146  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

children.  Tuberculosis,  marasmus,  and  chronic  gastroin- 
testinal diseases  are  the  usual  primary  conditions.  It  is 
fairly  common  in  infants. 

Pathology :  The  liver  is  large,  the  surface  is  smooth,  the 
color  is  yellow,  much  lighter  than  normal,  and  a  cut  section 
has  an  oily  appearance.  Under  the  microscope  fat-globules 
are  seen  in  the  liver-cells. 

Symptoms  :  There  are  no  subjective  symptoms.  A  uniform 
enlargement  of  the  liver  is  present.  There  is  no  pain  and 
no  tenderness.  If  the  fatty  degeneration  is  marked,  some 
interference  with  the  hepatic  functions  may  be  present,  but 
not  enough  to  give  any  marked  symptoms. 

Fatty  liver — treatment :  This  is  entirely  that  of  the  original 
disease  on  which  the  liver  condition  depends. 

AMYLOID  LIVER. 

Amyloid  degeneration  of  the  liver-cells  is  dependent  on 
chronic  suppurative  disease  in  other  parts  of  the  body. 
Chronic  bone-disease  is  the  commonest  precursor.  Phthisis, 
empyema,  and  hereditary  syphilis  are  less  common  primary 
causes.  This  condition  is  fairly  common  in  childhood.  The 
spleen  and  kidneys  are  likely  to  be  similarly  affected. 

Pathology :  The  liver  is  quite  large,  and  symmetrically  so. 
It  has  a  smooth  surface,  with  a  gray  waxy  color.  On  section 
it  is  fairly  firm.  Iodine  gives  a  mahogany  color  to  the  de- 
generated cells. 

Amyloid  liver — symptoms  :  There  are  no  special  symptoms 
from  the  liver  itself.  In  the  presence  of  the  original  disease, 
a  markedly  enlarged  liver,  with  no  pain,  no  tenderness,  and 
no  jaundice,  will  usually  be  waxy.  Slight  interference  with 
the  liver-functions  may  occur,  but  the  symptoms  are  so 
merged  with  those  of  the  primary  disease  as  to  give  them  no 
value.  The  spleen  is  regularly  enlarged,  and  the  urine  some- 
times shows  the  changes  seen  in  amyloid  kidneys. 

Amyloid  liver — treatment:  This  is  entirely  that  of  the 
primary  disease.  In  cases  where  the  originating  focus  can 
be  eradicated  cure  may  be  hoped  for,  but  otherwise  little  can 
be  expected. 


CIRRHOSIS  OF  THE  LIVER.  147 

CIRRHOSIS  OF  THE  LIVER. 

Cirrhosis  of  the  liver  is  quite  rare  in  infancy  and  childhood, 
but  from  time  to  time  cases  in  children  under  puberty  are 
reported. 

Etiology  :  Alcoholism  is  a  cause  as  in  adults.  Some  chil- 
dren inherit  an  appetite  for  liquor;  and  to  others  it  is  given 
medicinally  in  such  quantities  and  over  such  periods  as  to 
produce  in  the  liver  the  degenerative  changes  of  chronic 
alcoholism.  Syphilis,  malaria,  and  chronic  ptomain-absorp- 
tion  from  the  intestines  are  recognized  as  distinct  causes. 

Pathology :  There  are  two  general  varieties,  the  atrophic 
and  the  hypertrophic  cirrhosis.  The  latter  form  is  the  rarer 
in  children. 

In  the  atrophic  form  the  liver  is  smaller  than  normal;  its 
surface  rough  and  yellowish  ;  it  is  firm  and  hard  to  the  touch 
and  cuts  like  cartilage.  The  liver-structure  shows  a  marked 
increase  of  the  connective-tissue  stroma.  The  hepatic  cells 
are  atrophied  and  replaced  by  new  connective  tissue.  The 
smaller  veins  and  bile-ducts  may  be  obliterated. 

In  the  hypertrophic  variety  the  liver  is  enlarged,  firm,  and 
yellowish  colored.  The  new  growth  of  connective  tissue 
begins  around  and  follows  the  intralobular  branches  of  the 
bile-duct,  giving  a  more  uniform  distribution.  The  portal 
veins  are  less  interfered  with,  while  the  bile-ducts  are  more 
apt  to  be  destroyed.  From  this  distribution  of  the  connec- 
tive tissue  the  term  biliary  cirrhosis  is  often  applied  to  this 
condition. 

Cirrhosis  of  the  liver — symptoms :  In  the  early  stages  the 
symptoms  are  mainly  those  of  disturbance  of  the  functions 
of  the  liver.  Such  symptoms  as  furred  tongue,  bad  breath, 
bad  taste  in  the  mouth,  capricious  appetite,  and  constipation 
with  foul  stools  are  usually  first  noticed. 

After  some  time  the  more  definite  symptoms  of  the  disease 
develop,  as  vomiting,  hematemesis,  slight  ascites,  enlarged 
spleen,  diarrhoea,  bloody  stools,  and  haemorrhoids.  Slight 
jaundice  may  occur.  The  patients  lose  flesh  and  strength, 
and  become  anaemic. 

On  examination  the  liver  is  found  to  be  small,   the  spleen 


148  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

large,  and  the  presence  of  fluid  in  the  abdominal  cavity  can 
be  demonstrated.     There  may  be  albuminuria. 

The  hypertrophic  form  has  somewhat  the  same  symptoms, 
except  for  the  presence  of  a  marked  and  rather  malignant  form 
of  jaundice,  an  enlarged  liver,  and  usually  not  much  ascites. 

Toward  the  end  both  varieties  present  some  irregular  fever, 
with  low  delirium  and  other  cerebral  symptoms. 

Prognosis  :  This  is  quite  unfavorable.  The  course  of  the 
disease  is  slow,  although  seemingly  less  so  than  in  adults. 
The  hypertrophic  form  is  more  rapidly  fatal. 

Cirrhosis  of  the  liver — treatment :  If  any  causative  factor 
is  present,  remove  it  at  once.  A  milk-diet  is  the  best  for  this 
disease.  Any  tendency  to  congestion  in  the  portal  system 
should  be  relieved  by  the  use  of  salines.  The  patient  should 
be  out  of  doors  and  should  exercise  freely.  Plenty  of  water 
should  be  drunk  daily.  If  syphilis  is  present,  mercury  and 
iodide  of  potassium  are  to  be  used,  and  may  produce  good 
results.  Chloride  of  ammonium  also  seems  to  have  some 
value  in  this  disease.  The  ascites  is  to  be  relieved  by 
diuretics,  purging,  or  aspiration. 

HYDATIDS   OF  THE  LIVER. 

Hydatids  are  rare  in  the  United  States,  and  especially  rare 
in  children.  A  few  cases  are  reported  from  time  to  time. 
At  any  rate,  children  are  not  immune  to  the  disease. 

Hydatids  of  the  liver — etiology  :  They  are  produced  by  the 
development  in  the  liver  of  the  embryo  of  the  tapeworm  in 
its  larval  state.  The  eggs  of  a  tapeworm  are  swallowed  by 
the  child,  and  the  embryo,  being  set  free  in  the  stomach  or 
intestines,  travels  through  the  walls  of  the  viscus  and  is 
carried  by  the  portal  blood  to  the  liver.  Here  it  forms  a 
wall  about  itself,  and  develops  a  so-called  echinococcus-cyst. 
This  cyst,  growing  gradually  in  size,  is  the  hydatid. 

Pathology:  The  echinococcus  is  enclosed  by  a  thick  wall 
made  up  of  connective  tissue  from  the  organ  in  which  it  is 
growing.  The  cyst  is  single  (unilocular),  or  contains  smaller 
cysts  inside  the  larger  ones  (multilocular).  The  contents  are 
an  opalescent  fluid,  slightly  albuminous,  containing  crystals 
of  cholesterin  and  echinococcus  hoohlets  or  scolices. 


BILIARY  CALCULI.  149 

Hydatids  of  the  liver — symptoms  :  The  cyst  is  usually  latent 
for  some  time,  until  it  grows  large  enough  to  cause  symptoms 
by  its  mechanical  presence.  It  grows  very  gradually,  and 
often  a  good-sized  cyst  will  be  discovered  by  accident  on  ex- 
amination when  no  previous  history  has  been  present. 

Usually  the  first  thing  noticed  by  the  patient  is  an  enlarge- 
ment in  the  region  of  the  loin,  or  of  the  whole  abdomen. 
There  is  no  pain  and  no  tenderness.  Jaundice  is  rare,  only 
occurring  when  the  cyst  presses  on  the  hepatic  duct.  Press- 
ure on  the  portal  vein  may  produce  ascites.  The  cyst  may 
become  infected  and  suppurate,  giving  the  symptoms  of  en- 
capsulated, abscess.  The  cyst  may  rupture,  usually  as  the 
result  of  trauma.  This  may  take  place  into  the  stomach,  or 
bowel,  or  pleural  cavity,  or  lung,  or  peritoneal  cavity,  or  ex- 
ternally. 

Hydatids  of  the  liver — physical  signs :  The  liver  is  found 
enlarged,  and  usually  irregularly  so.  The  mass  may  point 
upward  to  the  lung,  or  downward  to  the  pelvis,  or  forward 
to  the  abdominal  wall.  If  the  prominence  can  be  palpated, 
it  is  found  to  fluctuate,  and  the  so-called  hydatid  fremitus,  a 
sort  of  tremor  of  the  cyst,  is  felt. 

By  aspiration,  the  typical  fluid  showing  the  presence  of 
cholesterin  and  hooklets  is  obtained. 

Diagnosis :  This  is  positively  made,  with  the  above  symp- 
toms and  physical  signs,  by  the  discovery  of  the  scoliees  in 
the  aspirated  fluid. 

Prognosis  :  If  a  diagnosis  is  made,  and  the  tumor  is  accessi- 
ble to  operation,  the  prognosis  is  good.  If  untreated,  the 
disease  is  apt  to  be  fatal. 

Hydatids  of  the  liver — treatment :  This  is  purely  surgical. 
The  cyst  should  be  opened  and  the  contents  evacuated. 
K very  bit  of  the  contents,  especially  all  the  small  "daughter? 
cysts,"  should  be  carefully  removed  to  prevent  recurrence. 
The  cavity  should  be  packed  and  allowed  to  granulate. 

BILIARY  CALCULI. 

Gall-stones,  although  ran;  in  childhood,  are  found  from  time 
to  time.  Probably  their  presence  is  often  overlooked  on  ac- 
count of  their  extreme  raritv. 


150  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Etiology :  They  are  caused  by  the  precipitation  from  the 
bile  of  its  solids.  Cholesterin,  bile-pigment,  and  lime  are 
the  main  constituents.  Probably  catarrh  of  the  bile-ducts 
enter  into  the  etiology,  by  causing  a  desquamation  of  the 
epithelium. 

Pathology  :  The  gall-stones  may  be  single  or  multiple.  In 
children  the  latter  condition  is  the  commoner.  They  are 
usually  small  and  faceted  from  mutual  pressure.  They  are 
rather  friable  and  of  a  brownish  color.  They  are  found 
usually  in  the  gall-bladder,  but  may  be  found  in  any  part  of 
the  hepatic  ducts.  The  mucous  membrane  of  such  a  gall- 
bladder, or  of  the  ducts  around  a  stone,  is  in  a  state  of  mild 
catarrhal  inflammation.  The  gall-bladder  may  be  dilated. 
Suppurative  inflammation  of  the  gall-bladder  or  of  the  ducts 
may  be  present. 

Biliary  calculi — symptoms  :  So-called  biliary  colic  is  the 
most  characteristic  symptom.  This  is  due  to  the  passage  of 
a  gall-stone  from  its  place  of  rest,  through  the  duct  to  the 
duodenum.  The  attack  begins  suddenly,  with  sharp  agoniz- 
ing pain  in  the  right  hypochondrium,  making  the  child  cry 
vigorously  and  roll  around  in  the  bed.  The  screaming  is 
incessant,  and  nothing  seems  to  relieve  the  pain.  The  skin 
is  pale  and  clammy,  and  vomiting  soon  begins.  After  some 
few  hours  of  this  suffering  the  temperature  rises,  and  a  chill 
may  accompany  this  rise.  In  highly  neurotic  children  con- 
vulsions may  take  place.  The  pain  may  continue  for  a  day 
or  more,  and  then  usually  ceases  as  suddenly  as  it  began.  By 
the  second  day  some  jaundice  is  usually  present,  with  bile- 
pigment  in  the  urine,  and  later  the  stools  may  be  clay-col- 
ored. 

On  examination  there  is  some  sensitiveness  over  the  region 
of  the  liver.  The  liver  itself  may  be  slightly  enlarged.  The 
gall-bladder  may  be  found  distended. 

The  above  is  the  history  of  an  attack  in  which  the  gall- 
stone passes  completely  through  the  common  duct  and  into 
the  duodenum.  Instead  of  complete  expulsion,  the  stone 
may  become  impacted  in  the  cystic,  or  common,  duct. 

If  it  remains  in  the  cystic  duct,  the  gall-bladder  becomes 
painfully  distended,  and  eventually  the  stone  may  be  pushed 


BILIARY  CALCULI.  151 

out ;  or  the  bile  in  the  bladder  may  be  absorbed  and  the 
bladder  gradually  contract  and  atrophy.  In  other  cases  the 
gall-bladder  becomes  the  seat  of  an  infectious  inflammation, 
with  formation  of  an  abscess. 

If  the  stone  is  impacted  in  the  common  duct,  the  pain  gradu- 
ally ceases,  but  the  jaundice  with  white  stools  increases. 
Later  the  duct  forms  a  dilatation  around  the  stone,  allowing 
the  passage  of  bile  around  it,  the  jaundice  disappears,  and 
the  bile  again  reaches  the  intestine.  This  impacted  stone 
may  thus  produce  no  trouble ;  but  there  is  always  danger  of 
the  ducts  being  infected,  causing  a  suppurative  inflammation 
which  spreads  to  the  liver  and  forms  multiple  abscesses  in 
that  organ. 

Biliary  calculi — diagnosis  :  Sudden  severe  pain  in  the  region 
of  the  liver,  associated  with  jaundice  and  slight  tenderness 
and  enlargement  of  that  organ,  are  the  points  for  diagnosis. 
Ordinary  intestinal  colic,  intussusception,  and  perforation  of 
some  abdominal  viscus,  must  be  thought  of  as  causing  similar 
attacks.  Renal  colic  may  simulate  these  cases  closely.  The 
faeces  should  be  searched  daily  after  such  an  attack,  to  en- 
deavor to  find  a  calculus. 

Prognosis  :  The  attack  itself  is  rarely  fatal.  One  attack  is 
likely  to  be  followed  by  others.  Cases  with  persistent  jaun- 
dice, or  with  infectious  inflammation  of  the  bile-passages, 
are  very  serious. 

Biliary  calculi — treatment :  The  pain  should  be  relieved  by 
hot  baths  and  the  hypodermatic  use  of  morphine.  Large 
quantities  of  the  latter  are  often  needed,  and  care  should  be 
taken  to  consider  the  fact  that  children  bear  opium  badly. 
Hot  stupes  sprinkled  with  chloroform  may  be  applied  to  the 
liver  region.  At  times  it  may  be  necessary  to  administer  an 
amesthetic  to  control  the  pain. 

After  the  attack  of  pain  is  over  treatment  should  be  di- 
rected to  the  prevention  of  further  formation  of  gall-stones. 
For  this,  the  did  should  be  regulated,  sugars  and  fats  being 
excluded,  abundance  of  water  should  be  drunk,  and  out-door 
exercises  should  be  enforced.  Doses  of  olive  oil,  of  phos- 
phate of  sodium,  and  of  other  salines  should  be  used  from  time 
to  time. 


152  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Of  late  years  the  surgery  of  the  gall-bladder  and  ducts  has 
made  great  strides,  and  all  chronic  cases  should  be  given  the 
benefit  of  surgical  advice. 

DISEASES  OF  THE  PANCREAS. 

PANCREATIC  CYST. 

Diseases  of  the  pancreas  are  rare  under  ail  circumstances, 
and  especially  among  children.  The  only  disease  of  clinical 
importance  is  cyst. 

Etiology :  This  is  due  to  blocking  of  the  pancreatic  duct 
and  retention  of  secretion  behind  the  point  of  obstruction. 
A  larger  or  smaller  cyst  may  result ;  only  the  larger  ones, 
however,  being  recognized. 

Pancreatic  cyst — symptoms :  There  is  nothing  definite  in 
the  symptomatology.  The  presence  of  a  fluctuating  tumor 
in  the  epigastrium,  with  ill-defined  signs  of  intestinal  indiges- 
tion and  with  malnutrition,  are  suggestive  of  this  condition. 
In  some  cases  the  urine  may  contain  sugar.  Exploratory 
puncture  with  a  clean  aspirating-needle,  by  withdrawing  fluid 
having  the  digestive  qualities  of  the  pancreatic  juice,  is  the 
only  positive  means  of  diagnosis. 

Treatment :  This  is  purely  surgical,  viz.,  incision  and 
drainage. 

DISEASES  OF  THE  SPLEEN. 

The  normal  spleen  of  a  child  lies  at  the  left  extremity  of 
the  diaphragm,  and  extends  along  the  ninth,  tenth,  and 
eleventh  ribs.  It  cannot  be  easily  percussed  or  felt  when  of 
normal  size.  If  enlarged,  the  lower  edge  can  be  easily  pal- 
pated, especially  on  deep  inspiration,  extending  below  the 
free  border  of  the  ribs.  If  much  enlarged,  it  may  be  felt 
extending  well  down  toward  the  ileum  and  often  the  notch 
on  the  anterior  edge  can  be  easily  made  out. 

The  only  pathological  change  that  takes  place  in  the  spleen 
that  is  evident  to  us  is  its  enlargement.  This  enlargement  is 
always  secondary  to  some  general  constitutional  state,  except 
in  a  few  very  rare  cases  of  primary  splenic  tumor. 


ENLARGEMENT  OF  THE  SPLEEN— ACUTE  PERITONITIS.  153 

ENLARGEMENT  OF  THE  SPLEEN. 

The  commonest  of  the  causes  of  acute  enlargement  of  the 
spleen  are  malaria,  typhoid  fever,  and  septicaemia.  Any  of 
the  infectious  diseases,  however,  may  cause  it  to  swell.  Such 
swelling  is  due  to  congestion,  and  the  spleen  becomes  very 
dark-red  and  soft.  When  the  infection  has  disappeared,  the 
spleen  returns  to  normal. 

There  are  also  a  number  of  chronic  conditions  in  which  the 
spleen  becomes  hypertrophied.  In  these  cases  the  chronic 
congestion  of  the  spleen  is  succeeded  by  a  growth  of  new 
connective  tissue,  so  that  the  spleen  becomes  harder  and  more 
fibrous  than  normal.  Such  diseases  are  tuberculosis,  syphilis, 
leukaemia,  Hodgkin's  disease,  amyloid  degeneration,  cirrhosis 
of  the  liver,  chronic  endocarditis  and  rachitis. 

The  other  causes  of  enlarged  spleen  are  primary  new  growths. 
Any  of  these  are  rare,  but  a  few  cases  of  sarcoma  and  of 
echinococcus  have  been  reported. 

Enlargement  of  the  spleen — treatment :  This  is  dependent 
on  the  original  cause.  In  some  of  the  chronic  cases  extirpa- 
tion by  surgery  is  advisable. 

DISEASES  OF  THE  PERITONEUM. 

ACUTE  PERITONITIS. 

Definition :  This  is  an  acute  inflammation  of  the  serous 
membrane  covering  the  abdominal  viscera.  The  inflamma- 
tion may  be  local,  confined  to  some  small  area  of  the  peri- 
toneum, such  as  that  covering  one  viscus ;  or  general,  when 
it  spreads  over  the  whole  peritoneum.  A  localized  peritonitis 
is  liable  to  become  general. 

Etiology:  Acute  peritonitis  occurs  quite  commonly  among 
new-born  infants,  even  being  found  in  intra-uterine  life.  It 
is  rarer  after  this  until  the  child  reaches  about  its  fifth  year. 
The  cause-  in  early  infancy  arc  such  as  take  their  origin  from 
the  umbilical  cord  and  navel. 

In  later  childhood  the  common  causes  are  abdominal 
traumatism,  surgical  operations  on  the  abdomen,  appendicitis, 
exposure  to  cold  and  wet,  intussusception,  strangulated  hernia, 


154  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

rupture  of  cysts  or  abscesses  into  the  peritoneal  cavity, 
ulcers,  ruptures  or  perforations  of  the  stomach  or  intestines, 
inflammations  of  the  uterus,  tubes,  or  ovaries,  rupture  or 
inflammation  of  the  bladder,  inflammation  or  abscess  of  the 
abdominal  lymphatic  glands,  and  diseases  of  the  vertebra?  or 
pelvic  bones.  It  may  complicate  rheumatism,  erysipelas, 
chronic  nephritis,  or  the  infectious  diseases.  Finally,  so- 
called  idiopathic  cases  occur  in  which  no  cause  can  be  dis- 
covered. 

There  are  always  found  various  micro-organisms  which  are 
the  exciting  causes  of  the  peritonitis.  The  peritoneum  is 
particularly  sensitive  to  these.  The  staphylococci  and  strepto- 
cocci are  commonly  found.  The  pneumococcus  and  bacillus 
coli  communis  are  also  frequently  present. 

Pathology  :  In  the  beginning  the  peritoneum  is  simply  con- 
gested, its  normal  shining  surface  becomes  dull,  and  the  sub- 
peritoneal vessels  are  visibly  enlarged.  The  surface  becomes 
roughened,  and  an  exudation  of  serum,  or  of  serum  and 
fibrin,  or  of  pus,  follows.  Either  form  of  exudate  may  be  in 
excess,  and  very  large  quantities  of  any  one  of  them  may  be 
present.  Adjacent  surfaces  of  inflamed  peritoneum  become 
loosely  adherent,  and  small  sacculated  collections  of  the 
exudate  may  thus  be  formed.  The  intestinal  walls  are  para- 
lyzed, and  the  intestines  are  distended  with  gas. 

If  the  disease  lasts  and  recovery  ensues,  these  adhesions 
become  organized  and  permanent.  The  formation  of  these 
adhesions  may  be  the  means  of  saving  the  patient's  life,  by 
walling  off  the  general  peritoneal  cavity  and  circumscribing 
the  peritonitis. 

Acute  peritonitis — symptoms :  Abdominal  pain  usually 
begins  early.  At  first  it  is  localized  over  the  inflamed  area, 
but  soon  spreads  and  becomes  general  even  when  the  inflam- 
mation may  be  fairly  circumscribed.  The  abdomen  is  very 
tender,  and  all  motion,  even  that  of  breathing,  increases  the 
pain.  On  this  account  the  respiration  is  almost  entirely 
costal.  There  is  marked  tympanitic  distention  of  the  abdo- 
men, and  the  patient  lies  on  his  back  with  the  knees  drawn 
up  to  relax  the  abdominal  parietes  as  much  as  possible. 
Vomiting  begins  early  in  the  disease  and  is  quite  intractable. 


ACUTE  PERITONITIS.  155 

The  bowels  are  usually  constipated,  not  even  much  gas  being 
passed,  but  in  some  cases  diarrhoea  may  be  present. 

The  temperature  is  moderately  high  with  quite  an  irregular 
curve.  The  pulse  is  rapid  and  feeble  and  wiry.  Respiration 
is  rapid  and  superficial,  the  diaphragm  being  nearly  immo- 
bile. The  tongue  is  coated  and  the  mouth  dry.  The  face  is 
drawn  and  shows  the  evidences  of  pain.  The  urine  is  scanty 
and  may  contain  albumin. 

All  the  cases  increase  in  severity  as  the  disease  advances, 
and  the  fatal  cases  usually  end  at  the  expiration  of  a  week  or 
less.     The  mind  is  usually  clear  throughout. 

Diagnosis :  This  disease  may  be  confused  with  intestinal, 
renal,  or  hepatic  colic ;  acute  gastritis,  or  entero-colitis,  and 
with  intestinal  obstruction.  A  little  care  will  soon  clear  up 
the  differential  points. 

It  is  not  only  necessary  to  diagnose  the  presence  of  peri- 
tonitis, but  a  careful  attempt  should  be  made  to  locate  the 
point  where  the  peritonitis  began  ;  in  other  words,  to  find  the 
causative  factor.  -  The  diagnosis  of  the  cause  of  the  peri- 
tonitis is  of  very  great  importance  from  the  therapeutical 
standpoint. 

Prognosis :  Localized  peritonitis  has  a  much  less  grave 
prognosis  than  the  generalized  form.  The  latter  is  a  very 
fatal  disease.  Seemingly  very  sick  cases,  however,  do  re- 
cover. 

Acute  peritonitis — treatment :  If  the  cause  of  the  attack 
can  be  found,  it  will  influence  the  treatment  markedly  (mainly 
from  a  surgical  standpoint).  Where  the  case  is  seen  earl)', 
and  the  evidence  points  to  some  localized  area  as  the  region 
of  the  inflammation,  surgical  interference  should  always  be 
considered.  An  example  is  seen  in  the  localized  peritonitis 
accompanying  appendicitis.  If  the  appendix  can  be  removed 
before  the  inflammation  spreads  to  the  general  peritoneal 
cavity,  the  patient  can   usually  be  saved. 

In  some  few  cases  recovery  has  been  recorded  following 
operation  even  after  general  peritonitis  had  set  in.  Abscesses 
in  the  peritoneal  cavity;  perforation  of  any  viscus;  and  intes- 
tinal obstruction  causing  peritonitis  are  definite  indications 
for  operation. 


156  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

The  medical  treatment  consists  of  rest  in  bed  and  con- 
tinuous cold  applications  to  the  abdomen.  This  may  be 
accomplished  by  ice-bags  or  the  cold  coil.  If  for  any  reason 
the  cold  is  very  objectionable  to  the  patient,  hot  applications 
may  be  substituted.  Turpentine  stupes — flannel  cloths  wrung 
out  of  hot  water  and  sprinkled  with  turpentine — are  also  very 
good  local  applications. 

The  question  of  diet  is  of  great  importance  on  account  of 
the  incessant  vomiting.  Food  is  very  likely  to  be  immedi- 
ately rejected.  If  any  form  can  be  retained,  it  must  be  pre- 
digested  and  given  in  very  small  quantities  at  a  time.  Pep- 
tonized milk,  peptonoids,  and  koumyss  are  all  allowable.  At 
times  gavage  will  assist  in  preventing  vomiting.  If  the 
stomach  rejects  these,  nutrient  enemata  of  predigested  foods 
must  be  used.  Cracked  ice  and  champagne  by  the  mouth 
will  usually  be  well  retained,  soothing  the  stomach  and  acting 
as  a  general  stimulant. 

If  the  peritonitis  is  recognized  in  the  very  beginning,  a 
saline  purge,  as  Rochelle  salts  or  citrate  of  magnesium,  in 
small  doses  every  hour  until  the  bowels  move,  will  frequently 
help.  It  acts  by  depleting  the  walls  of  the  intestine,  and  so 
may  cut  short  the  attack.  Any  time  later  the  saline  is  use- 
less, and  will  only  irritate  the  stomach.  From  this  time  on 
opium  should  be  used  freely.  There  is  probably  no  dis- 
ease in  which  such  large  quantities  can  be  safely  and  profit- 
ably used  as  in  acute  peritonitis.  It  is  best  given  hypoderma- 
tically,  and  in  doses  enough,  and  repeated  frequently  enough, 
to  stop  the  pain  absolutely,  and  to  paralyze  the  intestinal 
peristalsis.  Begin  with  about  -^  of  a  grain  of  morphine  for 
a  five-year-old  child,  and  repeat  it  in  about  two  hours  as  con- 
ditions point  the  way.  Atropine  may  be  well  combined  with 
it,  but  care  must  be  taken  not  to  produce  belladonna-poison- 
ing. Gas  may  be  removed  from  the  bowels  by  the  intro- 
duction of  a  long  soft-rubber  rectal  tube.  As  the  disease 
advances  heart-stimulants  will  be  required,  and  had  probably 
best  be  given  by  the  rectum  or  hypodermatically.  Alcohol, 
digitalis,  or  strychnine  may  be  used.  Special  symptoms  are 
to  be  treated  as  they  arise. 


CHRONIC  PERITONITIS.  157 

CHRONIC  PERITONITIS. 

Definition  :  This  is  a  rare  condition  in  children  when  com- 
pared with  the  tubercular  variety ;  but,  undoubtedly,  cases  of 
simple  chronic  peritonitis  do  occur. 

Etiology  :  It  may  follow  an  attack  of  the  acute  variety,  or 
be  chronic  from  the  outset.  It  may  be  the  result  of  a  chronic 
inflammation  extending  to  the  peritoneum  covering  some  one 
of  the  abdominal  viscera,  the  organ  itself  being  inflamed. 
Trauma  is  given  as  a  cause  in  many  cases.  In  the  largest 
number,  however,  no  adequate  exciting  cause  can  be  made  out. 

Pathology  :  There  is  a  general  thickening  of  the  peritoneum, 
due  to  the  growth  of  new  connective  tissue.  There  are  fre- 
quent adhesions  between  adjacent  portions  of  the  peritoneum, 
and  threads  and  membranes,  due  to  stretched  adhesions,  are 
seen  in  different  places.  There  is  a  good  deal  of  serum, 
which  may  be  slightly  purulent,  scattered  among  the  coils  of 
intestine. 

Chronic  peritonitis — symptoms :  The  symptoms  begin  very 
gradually,  with  some  interference  with  the  general  health, 
slight  digestive  disturbances,  and  irregular  colicky  pains  in 
the  abdomen.  The  abdomen  is  distended,  but  is  not  tender; 
nor  is  steady  pain  a  regular  symptom.  The  bowels  are  apt 
to  be  constipated,  but  diarrhoea  may  occur.  As  the  effusion 
takes  place,  the  abdomen  becomes  more  distended  and  the 
superficial  veins  become  prominent.  The  appetite  is  fair,  and 
the  strength  keeps  up  tolerably  well.  There  is  little  or  no 
fever,  but  the  pulse  gradually  loses  in  strength. 

If  the  case  continues  to  advance,  a  gradual,  slow  exhaus- 
tion supervenes,  from  which  the  patient  may  die,  or  some 
intercurrent  disease  carries  him  off.  If  recovery  is  to  ensue, 
the  fluid  is  gradually  absorbed,  the  strength  returns,  and  the 
various  organs  take  on  their  normal  functions. 

Chronic  peritonitis — physical  signs:  The  tympanitic  disten- 
tion of  the  abdomen,  together  with  a  feeling  as  if  the  bowels 
might  be  matted  together  ;  and,  if  fluid  is  present,  dulness 
in  the  dependent  parts  of  the  abdomen,  accompanied  by  a 
fluid  wave,  are  the  physical  signs  to  be  expected. 

Diagnosis:   If  fluid  is  present,  various  causes  for  this,  such 


158  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

as  endocarditis,  nephritis,  and  cirrhosis,  must  be  eliminated. 
The  difficulty  lies  in  differentiating  this  condition  from  tuber- 
cular peritonitis.  The  main  points  are  the  absence  of  any 
evidences  of  tuberculosis  elsewhere,  and  the  more  marked 
constitutional  symptoms  present  in  the  tubercular  variety. 

Prognosis :  Recovery  is  rather  to  be  expected,  although 
some  changes  of  a  permanent  nature  are  usually  left  behind, 
which  may  interfere  with  the  functions  of  the  intestines. 
Many  cases  gradually  grow  worse,  and  die  emaciated  and 
exhausted. 

Chronic  peritonitis — treatment :  The  child  should  be  kept 
at  rest,  with  plenty  of  fresh  air  and  sunshine,  and  under  the 
best  hygienic  surroundings.  The  diet  should  be  easily  di- 
gestible and  highly  nutrit.ous.  Milk,  eggs,  and  meat  should 
be  the  staples.  Carbohydrates  had  best  be  limited.  Hot 
applications,  or  chloroform  stupes,  or  some  irritant  liniment, 
should  be  applied  to  the  abdomen  for  some  time  each  day. 
The  syrup  of  the  iodide  of  iron  given  internally  seems  a 
good  tonic  treatment  to  be  used.  If  fluid  is  present,  occa- 
sional saline  purges  or  diuretics  should  be  used.  If  it  shows 
no  tendency  to  absorption,  the  abdomen  should  be  tapped. 
This  may  be  repeated  if  the  fluid  reaccumulates.  If,  after 
repeated  aspirations,  the  fluid  continually  returns,  laparotomy 
is  justifiable. 

TUBERCULAR  PERITONITIS. 

Occurrence  :  The  peritoneum  is  frequently  infected  by  tuber- 
culosis in  childhood.  The  disease  may  be  primary  in  the 
peritoneum,  and  at  autopsy  no  other  portion  of  the  body  may 
be  found  involved  ;  but  it  is  more  frequently  secondary  to 
tuberculosis  elsewhere. 

Etiology:  The  tubercle  bacillus  growing  in  the  peritoneum 
is  the  only  active  cause  of  the  disease.  The  bacilli  may  be 
carried  there  by  the  blood  or  lymph  without  involving  other 
organs  ;  but  usually  the  peritoneum  is  secondarily  infected 
from  the  lungs,  intestines,  mesenteric,  or  other  lymph-glands. 

Pathology:  The  peritoneum  may  contain  few  or  numerous 
small  miliary  tubercles  scattered  irregularly  over  its  surface, 


TUBERCULAR   PERITONITIS.  159 

and  no  other  changes  be  present.  In  some  cases  a  serous  ex- 
udation accompanies  this. 

In  other  cases  the  tubercles  may  be  massed  together  into 
large  nodules  or  plates.  Many  of  these  may  be  ensealing. 
With  these  are  numerous  adhesions  between  adjacent  portions 
of  the  intestines,  and  a  variable  quantity  of  sero-fibrinous  or 
purulent  exudation.  This  effusion  may  be  free  or  encapsu- 
lated, forming  a  cystic  tumor. 

In  advanced  eases  ulceration  of  the  tubercular  nodules  oc- 
curs, with  formation  of  small  abscesses  and  intestinal  per- 
foration. 

All  these  lesions  may  be  mixed  together  in  any  one  case, 
but  usually  one  or  the  other  pathological  variety  predomi- 
nates. In  some  cases  the  ascites  is  the  main  lesion,  in  others 
the  adhesions,  and  in  others  the  ulcerations. 

Tubercular  peritonitis — symptoms  :  Tubercular  peritonitis 
may  run  its  course  acutely  or  chronically ;  or  the  same  case  at 
different  times  may  show  decided  differences  in  the  course  of 
its  symptoms.     The  tendency,  however,  is  to  be  chronic. 

The  ascitic  cases  are  usually  the  more  rapid.  There  are 
irregular  fever  with  moderate  rises,  symptoms  of  indigestion, 
diarrhcea,  and  usually  some  abdominal  pain  or  discomfort. 
The  abdomen  enlarges  and  shows  the  presence  of  some  fluid, 
free  or  encapsulated,  and  the  intestines  give  a  feeling  as  of 
being  matted  together.  The  omentum  may  be  thickened,  and 
give  a  sensation  of  an  indefinite  tumor  extending  across  the 
upper  part  of  the  abdomen.  Tenderness  is  present,  but  is 
not  marked.  The  child  feels  sick,  is  weak  and  prostrated, 
and  loses  flesh  regularly.     Vomiting  is  seldom  present. 

In  the  variety  villi  adhesions,  all  the  symptoms  are  more 
chronic  and  gradual  in  their  development,  but  otherwise  do 
not  differ  much  from  the  above. 

In  the  variety  with  caseating  nodules  and  ulceration,  {\ww> 
are  more  marked  and  more  serious  constitutional  symptoms. 
The  temperature  is  higher,  and  often  assumes  a  hectic  course. 
Chills  ami  evidences  of  septic  absorption  are  present.  Diar- 
rhoea is  marked,  and  blood  and  necrotic  tissue  are  present  in 
tin'  stools.  The  abdomen  presents  irregular  areas  of  dulness 
and   tympanitic   resonance,     Tumor-  of  irregular  size  can  be 


160  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

felt  on  abdominal  palpation.  Encapsulated  fluid  can  be  often 
made  out.  The  abdominal  outlines  are  decidedly  asymmetri- 
cal. In  the  neighborhood  of  the  umbilicus,  the  abdominal 
wall  may  be  affected  by  contiguity,  and  an  abscess  burst 
through  and  discharge  itself. 

In  all  varieties  the  disease  steadily  progresses,  the  patient 
growing  weaker  and  weaker,  and  the  signs  of  the  disease  in- 
creasing, until  death  supervenes  from  exhaustion  or  tubercu- 
losis elsewhere.  The  cases  last  from  two  to  twelve  months, 
the  longer  ones  being  of  the  adhesive  variety. 

Diagnosis :  The  ascites  of  tubercular  peritonitis  must  be 
distinguished  from  that  due  to  cirrhosis  of  the  liver,  to 
chronic  endocarditis,  to  chronic  nephritis,  and  to  simple 
chronic  peritonitis.  The  last  is  the  hardest  to  differentiate. 
The  points  in  favor  of  tubercular  peritonitis  are  the  family 
history,  the  presence  of  any  evidences  of  tuberculosis  else- 
where, and  the  more  marked  constitutional  symptoms.  If 
there  is  no  ascites,  the  presence  of  evidences  of  matted  in- 
testines, or  of  irregular  masses  scattered  over  the  abdomen, 
is  in  favor  of  tubercular  peritonitis.  In  many  cases,  how- 
ever, it  will  be  almost  impossible  to  do  more  than  to  suspect 
the  presence  of  the  disease. 

Prognosis :  Many  cases  of  the  ascitic  and  adhesive  variety 
recover,  some  without,  and  more  with,  treatment.  The  ulcer- 
ative form  is  quite  fatal.     The  disease  is  very  serious. 

Tubercular  peritonitis — treatment:  The  constitutional  treat- 
ment of  the  patient  is  that  of  general  tuberculosis  :  rich, 
nourishing,  easily  digested  diet,  attention  to  the  functions  of 
the  stomach  and  intestines,  abundant  fresh  air,  and  the  ad- 
ministration of  creosote.  Local  applications  are  almost  use- 
less.    Aspiration  is  of  little  value. 

After  many  trials  it  has  been  found  that  laparotomy,  with 
evacuation  of  any  fluid  present,  and  washing  out  of  the  whole 
peritoneal  cavity  with  sterile  water,  will  cure  a  large  per- 
centage of  the  cases.  Any  variety  except  the  ulcerative  is 
amenable  to  this  treatment.  Tuberculosis  elsewhere  in  the 
body  is  not  a  contraindication.  The  reason  why  this  opera- 
tion is  curative  is  not  yet  decided  ;  in  fact,  no  satisfactory 
explanation  has  been  offered. 


CHAPTER    VII. 

DISORDERS   OF    NUTRITION. 

MALNUTRITION. 

This,  in  one  form  or  another,  is  a  very  common  occurrence 
in  children. 

Malnutrition — etiology :  The  tendency  to  malnutrition  may 
be  inherited  from  delicate  or  unhealthy  parents.  Persons  of 
highly  neurotic  constitution  are  often  the  parents  of  these 
children.  Infants  born  before  term,  or  of  unusually  light 
weight,  are  apt  to  be  affected.  But  commoner  yet,  it  is  seen 
in  children  who  in  early  infancy  have  been  fed  on  diet 
entirely  unsuitable  to  their  age.  Bad  hygienic  surround- 
ings, impure  air,  overheated  houses,  and  lack  of  proper 
cleanliness  are  also  causes.  Other  cases  follow  and  seem  the 
result  of  precedent  acute  disease,  as  the  infections,  broncho- 
pneumonia, or  some  form  of  intestinal  disease.  In  many  of 
the  cases,  two  or  more  of  the  causative  factors  are  active  at 
the  same  time. 

Pathology:  Nothing  further  is  found  than  an  anaemia  of  all 
the  tissues,  together  with  a  flabby  condition  of  all  the  organs. 

Malnutrition — symptoms  :  There  is  a  great  difference  in  the 
weigh!  of  these  infants  as  compared  with  a  normal  child  of 
the  same  age.  Not  only  do  they  weigh  less,  but  their  gain  in 
weighl  is  decidedly  slower.  The  child  also  grows  much  more 
slowly,  and  is  much  shorter  than  he  should  be.  The  muscles 
are  flabby  and  feeble,  and  sitting  up,  creeping,  and  walking 
arc  very  late  in  being  attempted.  Dentition  may  also  be 
delayed.  The  child  is  anaemic,  and  the  circulation  poor. 
The  various  lymph-glands  of  the  body  enlarge  easily  under 
slight  irritation.  The  digestive  functions  are  | rly  per- 
formed, and  greai  care  is  necessary  to  prevent  digestive  dis- 
order- from  developing.     The  resistance  of  these  children  to 

11-1'.  C.  ir,\ 


162  DISORDERS  OF  NUTRITION. 

any  acute  disease  is  very  small ;  not  only  do  they  seem  prone 
to  these  diseases,  but  if  the  disease  once  develops  they  have 
little  power  to  withstand  it. 

If  these  children  grow  up  they  usually  are  continuously 
cursed  by  the  presence  of  these  abnormal  conditions.  They 
frequently  have  in  addition  many  nervous  symptoms,  and 
may  develop  one  or  other  of  the  functional  neuroses.  Some 
never  outgrow  the  condition,  and  in  adult  life  exhibit  similar 
symptoms. 

Diagnosis :  In  diagnosing  such  a  disorder  great  care  should 
be  taken  to  rule  out  all  organic  disease  of  every  kind.  There 
are  many  latent  states  any  one  of  which  may  produce  just 
such  a  set  of  symptoms.  Tuberculosis,  syphilis,  rickets, 
malaria,  malignant  disease,  blood-diseases,  and  actual  disease 
of  any  of  the  important  organs  must  be  excluded.  Do  not 
make  the  diagnosis  of  simple  malnutrition  until  every  one  of 
the  possible  causes  is  eliminated. 

Prognosis :  This  depends  on  the  ability  to  find  and  remove 
the  cause.  The  cases  with  a  bad  heredity  are  the  least  favor- 
able for  cure.  When  due  to  bad  feeding,  or  bad  hygienic 
surroundings,  or  even  after  some  acute  disease,  they  can 
usually  be  cured. 

Malnutrition — treatment :  This  rests  on  the  proper  diagnosis 
of  the  causative  factor  of  the  condition.  If  it  is  decided  that 
the  food  is  at  fault,  steps  should  be  taken  to  remedy  this.  In 
very  young  children  a  wet-nurse  will  often  be  necessary.  If 
this  is  out  of  the  question,  artificial  feeding,  begun"  with  a 
dilute  modified  milk  which  is  gradually  changed  to  one  with 
higher  percentages  of  constituents,  is  the  best  method. 

In  children  on  mixed  diet  great  care  should  be  taken  to 
have  them  fed  only  on  such  food  as  can  be  easily  digested  by 
the  particular  child  ;  and  on  one  that  is  highly  nutritious. 
We  must  remember  that  often  in  such  children  food  suitable 
for  the  average  child  of  the  same  age  is  often  altogether  un- 
suitable. They  often  require  the  regular  diet  of  a  much 
younger  child.  In  every  way  the  problem  of  feeding  these 
children  is  a  difficult  one,  and  will  require  great  intelligence 
and  patience  on  the  part  of  both  physician  and  parent. 

If  the  sanitary  surroundings  are  bad,  these  must  be  changed. 


MARASMUS.  163 

Abundance  of  fresh  air  and  the  avoidance  of  overheated 
living-  and  sleeping-rooms  should  be  insisted  on.  Daily  cool 
baths  stimulate  the  various  functions  and  prevent  "  catching 
cold"  by  accustoming  the  child  to  changes  of  temperature. 
After  the  bath  thorough  rubbing  of  the  surface  before  a  warm 
fire  should  be  indulged  in.  Regular  habits  of  eating  and 
sleeping  should  be  enforced. 

In  children  able  to  walk  outdoor  exercises  are  to  be 
encouraged.  Habits  of  reading  and  studying  and  other 
sedentary  occupations  should  be  supervised. 

As  internal  treatment,  nux  vomica,  iron,  cod-liver  oil, 
and  wines  are  our  main  assistants.  Moderation  should  be 
used  in  the  amount  of  each  given.  Use  doses  only  large 
enough  to  be  assimilated  easily  by  a  child  of  the  age  at  which 
it  is  given.  This  is  of  special  importance  as  regards  iron  and 
cod-liver  oil. 

MARASMUS. 

Definition:  This  common  condition  of  wasting  is  also 
known  as  athrepsia,  or  infantile  atrophy.  Excessive  emacia- 
tion is  an  accompaniment  of  many  diseases  of  infancy,  par- 
ticularly of  tuberculosis  and  of  those  of  the  digestive  tract; 
but  in  this  condition  of  malnutrition  it  is  understood  that 
none  of  these  well-known  causative  factors  is  present.  In 
other  words,  marasmus  is  wasting  without  recognizable  organic 
lesion. 

Marasmus — etiology :  Marasmus  is  a  disease  of  the  first 
year  of  life,  but  cases  are  seen  with  some  frequency  even  in 
the  second  year.  It  is  seen  in  the  large  majority  of  cases  in 
artificially  fed  infants,  but  at  times  a  breast-fed  baby  is  the 
victim.  It  occurs  with  special  frequency  among  the  poor  and 
in  institutions.  It  might  almost  be  considered  an  institutional 
disease. 

Probably  three  factors  enter  into  the  causation  of  these 
cases:  an  inherited  delicate  comtitution,  improper  methods  of 
feeding,  and  imhygienic  surroundings.  There  is  an  inability  to 
digest  and  assimilate  the  food  given,  which  food  is  usually 
decidedly  improper ;  but  in  many  cases  is  such  as  properly 
nourishes  the  average  child  of  the  same  age.     In  fact,  the 


164  DISORDERS  OF  NUTRITION. 

two  other  elements,  and  possibly  something  further  which  is 
not  yet  recognized,  enter  into  the  case  as  well  as  the  feeding. 

Pathology :  After  death  the  results  of  the  marasmus  are 
found  rather  than  any  changes  which  may  be  looked  on  as 
causes.  The  muscles  are  atrophied,  all  fat  has  disappeared 
from  the  body,  and  fatty  degeneration  of  the  kidneys  and 
liver  is  often  present.  Some  hypostatic  pneumonia  is  fre- 
quently found  along  the  posterior  borders  of  the  lungs.  The 
stomach  shows  no  special  changes.  The  solitary  and  agmin- 
ated  follicles  of  the  intestines  are  usually  enlarged  and  may 
be  slightly  pigmented.  The  mesenteric  glands  may  likewise 
be  enlarged.  So  many  of  these  cases  die  of  some  intercurrent 
disease  that  other  lesions  due  to  those  diseases  are  present,  but 
in  a  pure  case  of  marasmus  nothing  further  is  found. 

Marasmus — symptoms :  The  disease  begins  gradually  and 
progresses  gradually.  Loss  of  weight  and  emaciation  are  the 
characteristic  features.  The  regular  infantile  plumpness 
gradually  disappears,  the  muscles  grow  soft  and  atrophy,  the 
skin  becomes  wrinkled  and  dry,  the  face  grows  thin,  pinched, 
and  pale,  the  anterior  fontanelle  becomes  depressed,  while  the 
abdomen  grows  prominent  and  distended.  Eventually  there 
seems  nothing  left  but  the  skeleton  covered  by  skin.  There 
is  marked  ansemia,  the  haemoglobin  often  being  only  one-third 
of  the  normal.  The  temperature  is  usually  subnormal,  even 
when  taken  by  rectum.  The  pulse  is  rapid  and  feeble,  and 
the  respirations  inefficient.  The  tongue  is  coated,  and  the 
mouth  is  frequently  the  seat  of  thrush.  The  appetite  is 
usually  voracious,  the  call  of  the  starved  tissues  for  nutri- 
ment being  strong  and  constant.  The  taking  of  food  does 
not  seem  to  satisfy  this  hunger,  and  naturally  so,  as  the 
tissues  do  not  receive  it.  Vomiting  is  rather  frequent  from 
the  constant  attempts  made  to  satisfy  the  appetite.  The  stools 
may  be  fairly  normal,  but  usually  contain  undigested  food. 
They  may  be  green,  and  of  offensive  odor,  and  are  usually 
large  in  amount  from  the  small  absorption  of  the  food.  The 
buttocks  are  regularly  excoriated  and  red,  and  bedsores 
develop  on  the  occiput,  sacrum,  and  heels. 

The  child  lies  quietly,  dozing  a  good  deal  of  the  time,  and 
constantly  sucking  the  fingers  and  hands.     Restless  sleep  and 


MARASMUS.  165 

fretfulness  may  be  present,  especially  when  the  child  is  dis- 
turbed. Nervous  symptoms,  twitching,  rolling  of  the  eye- 
balls, and  convulsions  are  frequently  present.  The  neck  is 
often  retracted.  The  disease  advances  steadily  to  a  fatal 
issue,  which  may  result  from  exhaustion,  from  convulsions, 
or  frequently  from  some  intercurrent  disease. 

Marasmus — diagnosis  :  The  diagnosis  rests  on  the  exclusion 
of  all  forms  of  organic  disease.  The  main  diseases  under  this 
category  are  tuberculosis,  congenital  syphilis,  and  chronic 
digestive  disturbances.  Tuberculosis  shows  the  physical 
signs  in  the  lungs,  and  is  associated  with  fever.  The  hypo- 
static pneumonia  of  marasmus  may,  however,  give  physical 
signs  that  are  confusing.  In  inherited  syphilis  the  child  has 
snuffles,  and  has  a  dry  skin  showing  some  form  of  rash.  The 
mouth  and  anus  show  mucous  patches.  In  digestive  dis- 
orders the  history  points  to  the  diagnosis. 

Prognosis :  The  prognosis  is  very  bad  in  young  infants,  in 
institutions,  and  among  the  poor  and  ignorant.  Even  under 
the  best  circumstances  it  is  often  difficult  to  start  the  nutrition 
on  the  up  grade.  Return  to  normal  is  complete  when  re- 
covery does  occur. 

Marasmus — treatment :  Attention  should  be  paid  to  the 
three  etiological  factors.  As  yet  we  have  no  way  of  improv- 
ing the  heredity,  but  the  sanitary  surroundings  can  be  changed 
for  the  better.  Plenty' of -fresh  air  should  be  given  all  infants, 
and  especially  should  this  be  so  in  all  institutions. 

The  question  of  diet,  the  third  factor,  is  of  vast  impor- 
tance. Wet-nursing  will  often  be  the  only  means  of  safely 
feeding  these  infants.  If  this  is  impossible,  modified  cow's 
milk  given  in  small  quantities  and  regularly  is  the  best  food. 
We  must  begin  with  a  dilute  milk  for  the  age,  and  gradually 
increase  the  ingredients  with  the  child's  ability  to  digest  them. 
Peptonized  milk  is  of  special  value  in  many  of  these  cases. 

The  child  should  be  bathed  regularly,  and  the  bath  finished 
with  :i  cold  douche  to  stimulate  the  respiration.  Thrush,  in- 
tertrigo, and  bedsores  must  be  treated  in  the  ordinary  way. 
Cod-liver  oil  is  much  used  in  this  condition  ;  but  its  utility 
depends  on  its  absorption,  and  in  very  many  of  the  cases  no 
absorption  takes  place.     The  children  should  be  kept  warm, 


166  DISORDERS  OF  NUTRITION. 

especially  when  the  temperature  is  subnormal.  Special  care 
should  be  used  to  prevent  them  from  contracting  any  acute 
disease,  as  such  diseases  are  very  fatal. 

SCORBUTUS. 

Definition:  This  is  commonly  called  scurvy.  It  is  a  con- 
stitutional disease,  which  in  infants,  until  recent  years,  has 
often  been  called  acute  rickets,  its  exact  classification  being 
unrecognized. 

Etiology  :  "  Infantile  scurvy  follows  the  prolonged  employ- 
ment of  some  diet  unsuitable  to  the  individual  child."  While 
no  one  particular  diet  seems  to  be  always  at  fault,  in  a  gen- 
eral way  "  the  farther  a  food  is  removed  from  the  natural 
food  of  a  child,  the  more  likely  is  its  use  to  be  followed  by 
the  development  of  scurvy."  The  lack  of  the  quality  of 
freshness  in  the  food  seems  to  be  the  most  marked  single 
factor.  The  proprietary  foods,  condensed  milk,  and  steril- 
ized milk  seem  to  have  the  most  cases  assigned  to  them  as  a 
cause.  A  few  cases  fed  on  breast-milk,  or  on  raw  cow's  milk, 
or  on  table  diet,  are  reported. 

The  disease  occurs  usually  during  the  first  two  years  of 
life.  The  largest  proportion  of  the  cases  are  seen  in  the 
better  walks  of  life.  It  is  not  any  more  common  in  the  city 
than  in  the  country. 

Pathology :  So  few  cases  of  scorbutus  die  that  opportunity 
for  pathological  investigation  is  rare.  The  changes  that  are 
found  are  those  due  to  hemorrhage.  In  an  affected  limb  there 
will  be  present  a  large  subperiosteal  hsematoma.  The  perios- 
teum will  be  stripped  from  the  bone,  and  in  bad  cases  detach- 
ment of  the  epiphysis  may  be  present.  The  bone,  especially 
in  the  neighborhood  of  the  epiphysis,  will  be  quite  congested. 

Scorbutus — symptoms :  The  patients  are  apt  to  be  ansemic 
and  show  signs  of  malnutrition  ;  but  these  signs  may  be  evi- 
dent only  to  a  skilled  observer,  a  layman  considering  the 
child  well  developed.  Scurvy  frequently  develops  in  a  rickety 
child,  although  there  is  no  relation  between  the  diseases. 

Usually  the  first  symptoms  that  definitely  point  to  scurvy 
are  pain  and  tenderness.     The  pain  may  be  present  when  the 


SCORBUTUS.  167 

child  is  at  rest,  but  usually  is  evident  only  on  moving  or 
handling  the  child.  This  tenderness  may  be  so  great  as  to 
cause  the  child  to  scream  if  anyone  approaches  him,  or  if 
the  least  movement  is  made  that  shakes  him.  On  searching 
for  the  situation  of  the  pain,  it  will  usually  be  located  in  the 
limbs.  Another  symptom,  which  is  a  direct  result  of  this 
tenderness,  is  a  pseudo-  or  voluntary  paralysis.  The  child 
holds  the  affected  limb  immobile,  in  order  to  prevent  the  pain 
which  results  from  motion ;  the  limbs  are  apt  to  be  kept  in 
a  flexed  position. 

If  now  the  extremities  are  carefully  examined,  there  will 
usually  be  found  a  more  or  less  marked  fusiform  swelling  of 
one  or  more  of  the  limbs.  These  swellings,  which  are  due  to 
the  subperiosteal  hemorrhages,  will  usually  be  found  involv- 
ing the  shafts  of  the  long  bones,  more  particularly  the  femur, 
tibia,  or  humerus,  and  extending  into  the  epiphyseal  area.  In 
some  cases  the  hemorrhages  are  confined  to  the  epiphyses,  and 
in  these  the  case  seems  more  like  a  joint-involvement,  and 
is  very  likely  to  be  mistaken  for  rheumatism.  There  may  be 
some  redness  around  these  joints,  but  it  is  not  regularly 
present. 

In  the  great  majority  of  cases  the  gums  are  affected  at  the 
same  time.  They  are  swollen,  spongy,  and  bleed  easily. 
Ulcerative  stomatitis  may  develop  from  these.  These  signs 
are  more  marked  in  cases  when  the  teeth  have  erupted,  but 
at  times  are  seen  in  infants  with  no  teeth.  Purpuric  and  ec- 
chymotic  spots  are  fairly  frequent.  They  may  occur  anywhere 
on  the  body,  but  are  quite  regularly  seen  about  the  eyes. 
Hemorrhages  from  the  mucous  membranes  may  be  present, 
such  as  those  of  the  stomach,  intestines,  or  nose.  There  is  no 
regular  fever  in  this  disease,  but  slight  elevations  of  tempera- 
ture may  occur.     Albuminuria  at  times  is  present. 

Cases  are  seen  of  all  degrees  of  severity,  from  mild  attacks 
of  tender  joints  to  very  marked  eases  with  hemorrhagic  gin- 
givitis and  large  subperiosteal  hemorrhages. 

Diagnosis:  The  three  conditions  most  likely  to  be  confused 
with  scurvy  are  rheumatism,  paralysis,  and  osteosarcoma.  If 
scurvy  is  always  kept  in  mind,  it  will  be  fairly  easy  to  make 
the    differential    diagnosis.      The    prompt     improvement   on 


168  DISORDERS  OF  NUTRITION. 

proper  treatment  offers  a  therapeutical  proof  of  the  diagnosis 
in  cases  of  doubt. 

Prognosis:  This  is  good.  Recovery  will  be  rapid  under 
proper  treatment.  Scurvy  occurring  in  a  case  of  severe 
marasmus,  or  other  condition  of  exhaustion,  is  naturally  a 
more  serious  disease. 

Scorbutus — treatment :  The  child  should  be  kept  as  quiet 
as  possible  to  protect  it  from  pain.  If  the  epiphysis  is  sepa- 
rated, the  limb  should  be  put  up  in  splints.  An  antiseptic 
mouth-wash  may  be  used  with  advantage. 

A  change  in  the  diet  is  imperative.  In  a  general  way  it 
may  be  said,  stop  all  proprietary  foods,  condensed  milk,  and 
sterilized  milk.  Put  the  child  on  raw  cow's  milk  and  orange- 
juice.  Beef-juice,  and  in  older  children  potato,  are  also  use- 
ful adjuncts. 

The  symptoms  may  be  confidently  expected  to  improve 
greatly  in  three  or  four  days,  and  cure  may  be  expected  in 
three  to  four  weeks.  After  improvement  begins  steps  should 
be  taken  to  correct  the  malnutrition  from  which  the  child  is 
usually  suffering.  This  can  be  best  accomplished  by  fresh 
air,  iron,  and  cod-liver  oil. 

RACHITIS. 

Rickets  is  a  constitutional  disease  with  its  main  pathologi- 
cal lesions  located  in  the  bones.  It  must  be  remembered, 
though,  that  almost  all  the  organs  of  the  body  take  part  in 
the  nutritional  changes. 

Etiology  :  Rickets  is  far  more  frequent  in  the  cities,  among 
the  ill-fed  and  badly  housed.  These  conditions,  together 
with  the  diet,  are  the  actual  causes.  Prolonged  feeding  on  a 
diet  which  does  not  contain  all  the  proximate  principles  of 
milk  in  comparatively  proper  quantities  is  regularly  a  cause. 
The  fat  first  and  the  proteids  second  are  usually  deficient. 
Condensed  milk  and  the  proprietary  foods  fulfil  this  con- 
dition of  lack  of  fat  and  proteids,  and  the  large  proportion 
of  cases  will  be  found  to  have  been  fed  on  one  or  the  other 
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RACHITIS.  169 

when  the  mother's  milk  is  deficient  in  quality,  will  produce 
rickets.  Two  nationalities  in  this  country,  the  negroes  and 
Italians,  seem  especially  prone  to  the  disease.  The  age  of 
greatest  susceptibility  seems  to  be  from  the  sixth  month  to 
the  end  of  the  second  year. 

Pathology :  Although  all  the  tissues  of  the  body  are  in- 
volved by  the  nutritional  changes,  still  the  lesions  evident  to 
the  naked  eye  are  mostly  in  the  bones.  There  is  a  general 
anasmia  of  the  voluntary  muscles,  and  of  those  of  the  heart. 
The  lungs  show  the  furrows  from  the  depressed  thorax.  The 
stomach  and  intestines  are  dilated  and  show  some  evidences 
of  chronic  catarrhal  inflammation.  The  spleen  is  enlarged. 
The  liver  and  kidneys  are  negative.  The  lymphatic  glands 
in  different  parts  of  the  body  are  apt  to  be  enlarged. 

In  the  bones  are  the  constant  signs  of  the  disease.  These 
changes  take  place  in  the  regions  of  the  bones  where  ossifica- 
tion is  in  progress.  These  regions  are  the  cartilage  between 
the  epiphysis  and  the  shaft,  underneath  the  periosteum,  and 
in  the  flat  bones  about  the  centres  of  ossification.  The  bones 
grow  by  the  proliferation  of  the  cartilage-cells  in  these  loca- 
tions, which  cartilage-cells  have  lime  salts  deposited  in  them, 
thus  undergoing  ossification.  In  rickets  the  proliferation  of 
these  cartilage-cells  is  stimulated  to  undue  activity,  while  the 
deposit  of  lime  salts  in  the  same  areas  does  not  keep  pace 
with  the  cartilaginous  growth.  The  result  of  these  abnormal 
changes  is  to  produce  a  marked  enlargement  at  the  epiphyses 
of  the  long  bones  and  at  the  centres  of  ossification  of  the  flat 
bones.  These  bones  become  very  soft  and  flexible  owing  to 
the  deficiency  of  lime  salts  in  them.  The  normal  two-thirds 
mineral  matter  is  reduced  to  one-third.  This  softness  and 
flexibility  explain  the  rachitic  deformities,  which  are  especially 
marked  where  the  bones  are  subject  to  muscular  action  or  to 
pressure,  as  in  the  femur,  tibia,  radius,  ulna,  or  the  ribs. 

A  section  through  the  epiphyseal  junction  of  a  rachitic  bone 
shows  a  very  vascular,  bluish-colored  condition,  which  is 
softer  than  normal  when  cut.  In  the  shaft  next  to  the  perios- 
teum the  bone  is  soft  and  thickened,  but  deeper  it  is  hard.  Sec- 
tion through  thickened  masses  on  the  flal  bones  shows  :i  spongy 
vascular  substance  which  is  soft  enough  to  be  indented  easily. 


170  DISORDERS  OF  NUTRITION. 

Microscopical  examination  shows  a  marked  increase  of  new 
cartilage-cells  and  increased  vascularity  of  the  proliferating 
zone.  The  areas  which  should  be  calcified  show  large 
quantities  of  cartilaginous  tissue  instead.  The  under  layer 
of  the  periosteum  is  very  vascular,  and  again  there  is  a  great 
excess  of  uncalcified  cartilage.  In  the  flat  bones  the  bony 
trabecule  are  eroded,  and  their  places  taken  by  newly  formed 
minute  blood-vessels. 

When  the  rachitic  process  ceases  and  recovery  begins,  this 
excessive  proliferation  stops.  Calcification  and  ossification 
of  these  tissues  take  place,  the  enlargements  due  to  the 
hyperplasia  are  absorbed,  and  the  bone  returns  to  a  normal 
condition  save  for  any  deformities  that  may  have  resulted 
during  the  activity  of  the  rachitic  process. 

Rachitis — symptoms  :  Rickets  is  a  slow  disease,  with  a  very 
gradual  onset  and  progression.  It  is  difficult  to  say  when  the 
disease  begins,  as  the  early  symptoms  are  not  marked  enough 
to  attract  much  attention.  A  fully  developed  case  of  the  dis- 
ease is  easily  recognized ;  but  it  is  of  more  practical  value  to 
be  able  to  diagnose  the  beginning  of  rickets,  so  as  to  prevent 
its  further  development. 

At  the  first,  we  may  expect  to  find  some  ancemia,  marked 
sweating  around  the  head  and  neck,  especially  during  sleep, 
and  slight  beading  of  the  ribs.  The  baby  is  restless  in  its 
sleep  and  is  usually  constipated.  The  hair  will  frequently 
be  rubbed  off  the  occiput  by  the  continual  rolling  of  the  head 
in  the  pillow. 

As  the  disease  advances  the  bony  changes  become  more 
prominent,  although  the  other  symptoms  still  continue.  The 
beading  of  the  ribs,  the  so-called  "  rachitic  rosary,"  increases 
until  the  little  lumps  are  evident  to  the  eye  through  the  skin. 
In  the  early  stages  they  are  evident  only  to  palpation.  The 
"beads"  are  due  to  overgrowth  of  cartilage  at  the  junc- 
tion of  the  ribs  with  the  costal  cartilages.  They  are  found 
at  the  end  of  each  rib,  the  row  thus  made  running  downward 
and  outward  to  the  costal  margin.  The  same  beading  is 
found  on  the  inner  side  of  the  thorax,  but  naturally  only 
shows  in  this  situation  post  mortem.  The  atmospheric  press- 
ure exerted  on  these  softened  ribs  causes  in  advanced  cases 


RACHITIS.  171 

a  marked  depression  of  the  thorax  in  a  line  parallel  with  and 
on  each  side  of  the  sternum,  and  just  along  the  course  of 
these  beads.  A  second  depression  is  also  frequently  present 
extending  in  a  horizontal  direction  around  the  lower  portion 
of  the  thorax,  and  is  probably  due  to  traction  of  the  dia- 
phragm on  the  lower  ribs.  The  sternum  is  apt  to  be  pro- 
truded, or  at  times  depressed,  by  this  same  action  of  the 
atmospheric  pressure,  causing  the  deformity  known  as  pigeon- 
breast  or  funnel-breast. 

The  vertebrce  likewise  are  partially  softened,  and  the  weight 
of  the  head  and  shoulders  on  these  causes  a  posterior  or  lat- 
eral bending  of  the  spinal  column.  The  kyphosis,  or  scoliosis, 
so  produced,  forms  a  long,  regular  curve,  no  sharp  angles 
being  found  in  rachitic  spines.  In  the  early  stages  these 
curvatures  will  disappear  when  the  child  lies  down  or  is  sus- 
pended, but  in  the  long-standing  cases  the  deformity  becomes 
permanent. 

The  changes  in  the  cranium  are  well  marked  and  charac- 
teristic. The  head  appears  large  and  square,  the  forehead 
broad  and  projecting,  the  top  is  flattened,  and  the  suggestion 
of  two  furrows  crossing  each  other  at  the  anterior  fontanelle 
at  right  angles  is  often  present.  These  appearances  are  due 
to  the  thickened  masses  of  bone,  called  "bosses"  which  exist 
at  the  frontal  and  parietal  eminences.  These  bosses  often 
grow  quite  thick  and    prominent. 

In  the  occipito-parietal  regions  are  frequently  found  soft 
spots  in  the  bones.  This  condition  is  known  as  crauiotabes. 
( J  a  pressure  with  the  finger  these  small  areas  dent  in,  but 
spring  out  again  when  the  pressure  is  removed.  Crauio- 
tabes is  seen  in  syphilis   as  well  as  in   rickets. 

The  sutures  and  fontanelles  arc  very  late  in  closing;  often 
the  anterior  fontanelle  will  be  open  at  the  end  of  the  second 
or  even  the  third  year.  The  veins  of  the  scalp  seem  large, 
and   are   plainly  outlined   through   the   thin   skin. 

The  teeth  are  cut  quite  late,  are  often  irregular  in  the  order 
of  their  appearance,  and  are  subject  to  early  decay.  The 
various  disturbances  connected  with  dentition  are  more  apt 
to  be  seen  in  rachitic  children  than  in  normal  ones. 

Changes   in  the  long  bones  of  the  limbs  are  seen  early  and 


172  DISORDERS   OF  NUTRITION. 

constantly.  The  earliest  is  an  enlarged,  rounded  knob,  found 
at  the  epiphyseal  junctions.  The  wrists,  ankles,  and  knees 
show  this  change  most  commonly  and  in  the  order  named. 
Other  joints  may  be  affected  in  the  most  severe  cases.  Later 
the  long  bones  become  bent  into  abnormal  curves.  These 
bendings  are  most  marked  in  the  leg,  thigh,  and  forearm,  but 
the  upper  arm  may  also  be  affected. 

In  the  forearm  the  bones  are  usually  bowed  backward,  and 
in  the  upper  arm  outward.  It  is  in  the  legs  though  that  the 
deformities  are  most  marked.  The  usual  variety  is  bowing 
outward  of  the  tibia;,  and,  in  marked  cases,  of  the  femora 
also,  producing  the  condition  known  as  bow-legs  or  genu 
varum.  In  these  patients,  when  the  feet  are  put  together, 
the  knees  are  far  apart.  In  others  the  opposite  condition  of 
knock-knee,  or  genu  valgum,  is  present.  In  these  the  inner 
condyles  of  the  femur  are  hypertrophied,  so  that  when  the 
knees  are  put  together  the  feet  are  far  apart,  the  legs  making 
an  obtuse  angle  with  the  thighs.  In  very  severe  cases  the 
rachitic  softening  is  so  marked  that  irregular  and  very  dis- 
tressing deformities  in  the  long  bones  are  produced. 

In  the  pelvic  bones  rickets  causes  certain  changes  that  are 
of  importance  only  from  an  obstetrical  standpoint,  since  the 
deformity  may  interfere  with  the  passage  of  the  child  through 
the  pelvis.  The  usual  deformity  of  rickets  is  a  decided  short- 
ening of  the  antero-posterior  diameter  of  the  pelvis,  from 
pushing  forward  of  the  sacrum. 

The  ligaments  about  all  the  joints  are  relaxed  and  weak- 
ened, thus  assisting  in  the  production  of  the  deformities.  The 
muscles  also  are  flabby,  small,  and  feeble,  so  that  sitting  and 
standing  are  difficult  for  these  children.  Walking  is  always 
learned  late,  and  at  times  they  are  first  brought  to  the  physi- 
cian to  know  why  they  do  not  walk,  the  mother  dreading 
paralysis. 

Children  with  rickets  may  be  either  fat  and  seemingly  well 
nourished,  or  thin  and  suffering  from  malnutrition.  Almost 
always  they  are  anmmic. 

The  abdomen  is  enlarged  and  tympanitic,  for  which  there 
are  two  probable  reasons  :  the  pressing  downward  of  the  dia- 
phragm from  the  diminished  chest-capacity,  and  the  disten- 


RACHITIS.  173 

tion  of  the  stomach  and  intestines  from  the  accompanying 
chronic  indigestion. 

The  pulse  and  temperature  are  about  normal.  A  bruit 
may  often  be  heard  over  the  anterior  fontanelle,  but  is  of  no 
special  significance.     The  urine  is  negative. 

Rachitic  children  are  quite  prone  to  catarrhal  inflammations 
of  the  gastro-intestinal  tract  or  of  the  respiratory  system. 
The  reflex  excitability  of  their  nervous  systems  is  highly  ex- 
aggerated, and  laryngismus  stridulus,  tetany,  and  general 
convulsions  are  frequent. 

The  course  of  rickets  is  chronic,  and  the  disease  usually 
lasts  for  one  or  two  years.  Spontaneous  recovery  regularly 
occurs,  as  the  child  is  put  on  a  mixed  and  nourishing  diet. 

Diagnosis :  In  a  developed  case  the  diagnosis  is  not  diffi- 
cult, and  hydrocephalus  is  the  only  disease  with  which  it  may 
be  confused.  A  careful  examination  of  the  head,  and  the 
presence  of  rickety  changes  elsewhere,  are  the  deciding  points. 

In  mild  cases  careful  examination  for  beginning  changes  in 
the  bones,  at  the  epiphyses  and  costal  cartilages,  will  usually 
settle  the  diagnosis.  Any  of  the  bony  signs  are  sufficient  to 
establish  the  presence  of  rachitis,  when  the  child  is  supposed 
to  be  suffering  only  from  an  emia,  debility,  or  even  from 
paralysis. 

Prognosis :  The  disease  is  self-limited,  and  will  usually  re- 
cover spontaneously  when  the  diet  becomes  such  as  to  furnish 
the  proper  nutrition.  Rachitis  is  seldom  fatal  in  itself,  but 
from  its  tendency  to  act  as  a  predisposing  cause  of  gastro- 
intestinal, respiratory,  and  nervous  diseases,  it  is  partially 
responsible  for  much  infantile  mortality. 

The  bony  deformities  which  have  taken  place  during  the 
disease  are,  as  a  rule,  permanent  throughout  life. 

Rachitis — treatment:  Proper  attention  to  the  hygienic  sur- 
roundings and  care  with  the  food  are  the  two  general  points 
to  be  followed  both  in  the  prevention  and  in  the  treatment 
of  rachitis. 

The  children  should  be  kept  in  cool,  dry,  well-ventilated 
rooms.  They  should  be  given  as  much  out-of-door  life  as 
possible,  and  particularly  plenty  of  sunshine.  Each  day  they 
should   be  given  a  cool   bath  to  stimulate   the  respiration  and 


174  DISORDERS  OF  NUTRITION. 

circulation,  and  to  accustom  the  system  to  changes  in  temper- 
ature, and  thus  do  away  with  the  tendency  to  "  catching  cold." 

The  diet  should  be  made  to  conform  as  nearly  as  possible 
to  the  normal  for  a  child  of  the  same  age.  Proprietary  foods 
and  condensed  milk  should  especially  be  avoided.  An 
abundance  of  fats  and  proteids  should  be  given,  while  the 
carbohydrates  should  be  diminished.  Cream,  beef-juice,  and 
scraped  beef  fulfil  these  conditions  admirably. 

As  regards  drugs,  three  are  used  quite  regularly,  and  all 
rationally.  They  are  cod-liver  oil,  phosphorus,  and  lime. 
Cod-liver  oil  is  given  more  as  a  fat  food  than  a  drug,  in  just 
sufficient  dosage  to  be  absorbed  easily  and  not  to  upset  the 
digestion.  Phosphorus  is  given  in  doses  of  ^-jro  ^°  Tiro  °^  a 
grain  three  times  a  day.  Thompson's  solution,  containing 
one-twentieth  of  a  grain  to  the  drachm,  is  the  easiest  way  of 
giving  it.  Lime  is  best  given  as  the  hypophosphite  of  calcium. 
If  the  child  is  anaemic,  iron  as  the  syrup  of  the  iodide  is 
useful. 

During  the  active  stage  of  the  disease  attention  should  be 
given  to  the  prevention  of  bony  deformities  as  far  as  possible, 
by  keeping  the  child  from  making  too  much  mechanical  ex- 
ertion. Light  supports  and  braces  may  often  be  used  with 
advantage.  If  marked  deformities  are  present  after  the  cure 
of  the  disease,  orthopaedic  apparatus  may  be  tried,  but  oste- 
otomy will  usually  be  necessary  to  straighten  the  bones. 

DIABETES  MELLITUS. 

Diabetes  mellitus  :  This  is  a  rare  disease  in  children,  and  is 
probably  as  well  grouped  under  the  errors  of  nutrition  as 
elsewhere,  in  the  present  state  of  our  knowledge.  It  is  a  far 
more  serious  disease  in  childhood  than  in  adults,  its  serious- 
ness being  inversely  to  the  age. 

Etiology :  It  is  commoner  in  girls  than  in  boys,  and  there 
is  an  hereditary  element  present  in  many  of  the  cases.  Other- 
wise nothing  is  known  as  to  the  causes. 

Pathology :  There  are  no  recognized  pathological  facts  con- 
nected with  diabetes  other  than  the  occasional  association  of 
pancreatic  disease  and  diabetes. 


ACUTE  RHEUMATISM.  175 

Diabetes  mellitus — symptoms :  The  symptoms  are  frequent 
urination,  which  is  found  to  be  due  to  increased  secretion  of 
urine,  great  thirst,  increased  appetite,  and  wasting.  On 
examining  the  urine  the  specific  gravity  is  high,  and  sugar  is 
present  in  larger  or  smaller  quantities.  As  the  case  advances 
albumin  may  also  be  found  in  the  urine.  Loss  of  weight  is 
very  rapid,  the  skin  becomes  dry,  and  constipation  is  apt  to 
be  present.  Furunculosis  may  exist  as  a  complication.  Der- 
matitis about  the  genitals  may  develop  from  the  irritation  of 
the  glycosuric  urine  on  the  skin.  This  is  commoner  in 
girls.  The  disease  progresses  rapidly,  and  a  fatal  termination 
usually  comes  before  six  months  from  the  outset.  Diabetic 
coma  is  the  usual  cause  of  death.  A  few  die  of  pneumonia 
or  tuberculosis. 

Diagnosis  :  This  is  based  on  the  urinary  analysis,  a  method 
of  examination  too  seldom  used  in  dealing  with  children. 

Prognosis  :  This  is  very  bad,  almost  surely  fatal,  in  child- 
hood. 

Diabetes  mellitus — treatment :  This  differs  in  no  wise  from 
that  in  adults.  The  diet  should  contain  as  little  carbohydrates 
as  possible,  milk,  meat,  and  eggs  being  the  staples.  Good 
hygiene  should  be  insisted  on — fresh  air,  exercise,  and  bath- 
ing. As  drugs,  codeine  given  regularly  seems  the  most 
valuable  one.  Arsenic  and  the  salicylate  of  sodium  have 
some  reputation  as  being  of  value. 

ACUTE  RHEUMATISM. 

Nature :  We  are  still  in  the  dark  as  to  the  true  nature  of 
rheumatism,  and,  as  there  is  evidence  as  to  its  being  due  to 
faulty  f  issue-metamorphosis,  it  is  hero  classified  mainly  as  a 
matter  of  expediency.  In  fact,  rheumatism  in  childhood  is 
inure  of  a  diathesis  with  local  evidences  breaking  out  in 
various  portions  of  the  body,  than  distinctly  ;i  joint-disease 
as  it  is  looked  on  in  adults.  Cases  are  seen  with  the  joint- 
symptoms  so  very  slight  that  they  are  entirely  overlooked. 

Etiology:  Nothing  is  as  yet  positively  known  on  this  point. 
There  may  be  more  than  one  exciting  cause  at  work  at  the 
same    time.      There  may  be  some  poisonous  substances,  due  to 


176  DISORDERS  OF  NUTRITION. 

faulty  metamorphosis  of  the  tissues,  floating  in  the  body-fluids, 
which  irritate  and  inflame  the  serous  membranes ;  or  there 
may  be  specific  micro-organisms  at  work  as  the  cause.  He- 
reditary influences  play  a  certain  part,  and  exposure  to  cold 
and  damp  undoubtedly  acts  as  an  assistant  exciting  cause. 

Acute  rheumatism — pathology :  The  inflamed  membrane, 
whether  it  be  in  a  joint,  the  pericardium,  or  the  endocardium, 
is  congested,  and  may  show  slight  hemorrhagic  spots.  There 
is  an  increased  secretion  of  serum  accompanying.  The  tissues 
in  the  neighborhood  are  swollen  by  inflammatory  effusion, 
which  may  contain  fibrin,  leucocytes,  and  at  times  red  cells. 
The  articular  cartilages  are  also  swollen  and  inflamed.  Sup- 
puration is  very  rare. 

Acute  rheumatism — symptoms  :  Rheumatism  in  childhood 
is  seldom  of  the  very  acute  type  so  often  seen  in  adults,  but 
is  more  apt  to  be  subacute  in  its  manifestations.  The  general 
symptoms  are  those  of  more  or  less  fever,  which  is  regularly 
lower  than  102°  F.,  and  which  runs  an  irregular  and  rather 
short  course ;  and  its  accompaniments,  malaise,  anorexia,  at 
times  nausea  and  vomiting,  some  delirium,  and  a  more  or 
less  free  perspiration.  At  the  same  time  one  or  more  joints 
become  painful  and  may  appear  a  little  swollen  and  red. 
These  joint-symptoms  may  be  so  slight  as  to  give  no  signs 
save  a  little  tenderness  on  use.  The  urine  is  of  high  specific 
gravity  and  deposits  urates  on  standing.  The  child  may  not 
feel  sick  enough  to  desire  to  go  to  bed.  These  attacks  are 
often  called  "  growing  pains "  by  the  family.  The  attack 
usually  lasts  only  one  or  two  weeks. 

In  other  cases  no  joint  may  be  affected,  but  the  rheumatic 
poison  centres  itself  in  some  one  of  the  muscles.  The  muscles 
most  commonly  affected  are  the  deltoid,  the  trapezius,  and 
sternomastoid,  those  of  the  lumbar  region,  or  the  intercos- 
tals.  In  such  cases  there  are  scarcely  any  constitutional 
symptoms,  the  only  sign  being  pain  on  motion  in  the  affected 
muscles,  and  at  times  some  continuous  spasm  of  the  same. 

In  other  children,  and  unfortunately  fairly  often,  with  very 
slight  joint  or  muscular  signs,  the  poison  especially  attacks 
the  pericardium  or  endocardium.  This  is,  of  course,  far  more 
serious.     In   fact,  the  heart  is  more  frequently  involved  in 


ACUTE  RHEUMATISM.  177 

children  than  in  adults,  and  at  times  the  only  way  of  feeling 
sure  that  the  child  has  been  suffering  from  rheumatism  is  by 
finding  a  murmur  or  a  friction-rub.  No  case  that  is  even 
suspicious  of  rheumatism  should  be  allowed  to  go  a  day 
without  a  careful  examination  of  the  heart.  Heart-compli- 
cations, as  a  rule,  give  no  special  symptoms,  except  a  slightly 
rapid  or  irregular  heart-action,  or  a  little  precordial  pain  if 
pericarditis  develops. 

In  other  cases  the  rheumatic  diathesis  is  evidenced  by  an 
outbreak  of  chorea,  either  with  or  without  signs  in  the  joints; 
and  in  others  by  an  attack  of  acute  tonsillitis,  or  by  recurrent 
attacks  of  the  same ;  in  others  subcutaneous  nodules  are  found 
developing  on  almost  any  of  the  fibrous  structures  of  the 
body.  They  are  mainly  about  the  joints  and  in  the  sheaths 
of  tendons,  and  vary  in  size  from  a  pinhead  to  an  almond. 
They  seem  particularly  associated  with  cardiac  disease.  They 
are  not  tender  and  not  permanent. 

Cutaneous  eruptions,  either  erythematous  or  even  purpuric, 
are  often  developed  by  the  rheumatic  diathesis.  Rheumatism, 
no  matter  in  what  variety  it  manifests  itself  objectively,  is 
always  accompanied  by  a  rapidly  developing  ancemia. 

Acute  rheumatism — diagnosis  :  The  slightness  of  the  joint- 
affection  makes  the  diagnosis  difficult  at  times.  Previous 
similar  attacks,  or  attacks  of  tonsillitis,  or  a  rheumatic  family- 
history  assist.  Signs  of  pericarditis,  or  of  endocarditis,  or 
rash,  or  fibrous  nodules,  or  chorea,  are  the  best  evidence. 
Scurvy,  rachitis,  tuberculosis,  and  pyaemia  are  to  be  differ- 
entiated.    By  care  no  confusion  need  exist. 

Acute  rheumatism — prognosis  :  This  is  good  in  every  way 
except  as  regards  the  development  of  heart-lesions.  The 
heart-lesions  become  permanent;  but  the  changes  in  the  joints 
and  muscles,  the  chorea,  the  fibrous  nodules,  and  the  tonsillitis 
are  curable.  A  bad  point  in  the  prognosis  is  the  tendency 
for  further  attacks  to  develop  after  the  first. 

Acute  rheumatism — treatment:  A  child  with  any  of  the 
rheumatic  manifestations  should  be  an  object  of  care  for  the 
prevention  of  heart-lesions.  He  should  be  kept  at  rest  in 
bed,  and  in  an  equable  temperature,  till  all  signs  have  disap- 
peared.    After  an  attack   is  over  lie   should   be  constantly 

12—1).  c. 


178  DISORDERS  OF  NUTRITION. 

under  supervision  to  prevent  subsequent  attacks.  He  should 
wear  flannel  underclothing  and  should  be  kept  from  all  damp 
surroundings,  and  especially  from  wet  feet. 

During  the  attack  the  inflamed  joint  or  muscle  should  have 
hot  local  applications  made  to  it,  and  should  be  rubbed  gently 
with  chloroform  liniment.  Internally  the  salicylate  of  sodium 
or  the  oil  of  wintergreen  should  be  given  in  fairly  large 
doses.  In  some  cases  citrate  of  potassium  in  doses  large 
enough  to  keep  the  urine  alkaline  should  be  used.  It  may  be 
profitably  combined  with  the  salicylate.  During  the  fever 
the  best  diet  is  milk  ;  later  it  may  be  more  varied.  Water 
should  be  drunk  freely.  After  the  attack  iron  is  indicated 
to  combat  the  ansemia.  The  heart-lesions  and  chorea  are 
treated  as  usual. 


CHAPTER    VIII. 
DISEASES   OF  THE   CIRCULATORY  SYSTEM. 
DISEASES  OF  THE  HEART  AND  PERICARDIUM. 

CONGENITAL  HEART-DISEASE. 

All  abnomalities  found  in  the  heart  at  birth  are  classified 
under  this  head.  Some  form  of  congenital  heart-lesion  is 
found  with  moderate  frequency. 

Congenital  heart-disease — etiology :  The  causes  are  well 
grouped  under  three  headings:  1.  Non-closure  of  openings 
existing  normally  in  foetal  life.  These  are  the  foramen  ovale 
leadino;  from  the  right  to  the  left  auricle,  and  the  ductus 
arteriosus  connecting  the  pulmonary  artery  with  the  descend- 
ing aorta.  2.  Actual  developmental  areas.  These  are  par- 
tial or  complete  absence  of  the  septa,  between  the  auricles  or 
ventricles;  transposition  of  the  great  vessels;  atresia  or  absence 
of  one  of  the  valves.  3.  Endocarditis  occurring  during 
foetal  life.  This  is  capable  of  producing  any  of  the  lesions 
which  follow  endocarditis  of  post-natal  life. 

Pathology:  The  commonest  lesions  found  are  absence  or 
defects  of  the  ventricular  septum,  patent  foramen  ovale, 
stenosis  of  the  pulmonary  artery,  persistent  ductus  arterio- 
sus, and  abnormalities  in  the  origin  of  the  great  vessels. 
Many  lesions  are  found  connected  with  the  valvular  open- 
ing-, both  stenoses  and  insufficiencies,  but  in  nowise  differing 
from  the  same  lesions  as  seen  in  ordinary  endocarditis,  excepf 
that  the  right  side  of  the  heart  is  more  often  involved  than 
the  left.  A  large  number  of  the  cases  have  more  than  one 
lesion  existing  at  the  same  time,  as  if  when  a  defect  occurred 
a  partial  endocarditis  was  engrafted  on  it.  The  heart  is 
ordinarily  hypertrophied,  as  the  result  of  the  extra  work 
thrown  on   it  by  these  anomalies. 

179 


180  DISEASES  OF  TEE  CIRCULATORY  SYSTEM. 

Congenital  heart-disease — symptoms :  Cyanosis  and  the 
presence  of  a  murmur  are  the  characteristic  signs  of  this  con- 
dition. The  cyanosis  is  present  continuously  in  most  of  the 
cases,  but  may  be  developed  only  by  exertion,  as  crying, 
coughing,  or  vomiting.  At  any  rate,  it  is  always  intensified 
by  such  action.  The  blueness  is  due  to  imperfect  oxygenation 
of  the  blood,  and  is  present  in  all  the  tissues.  The  mucous 
membranes,  as  the  lips  and  tongue,  appear  very  purplish. 

The  murmur  heard  over  the  heart  is  usually  rough  and 
loud,  and  systolic  in  time.  It  may  be  heard  loudest  at  the 
base  or  apex.  Murmurs  synchronous  with  the  other  heart- 
sounds  are  rare.  It  is,  however,  impossible  to  diagnose  the 
form  of  lesion  by  the  variety  of  murmur,  as  many  different 
pathological  changes  produce  the  same  murmur. 

There  are  cases  of  undoubted  congenital  heart-disease  with 
absolutely  no  murmur,  the  cyanosis  being  the  only  symptom 
present. 

Hemorrhages  from  the  nose  and  elsewhere  are  fairly  com- 
mon. A  result  of  the  chronic  congestion  of  the  tissues  is 
seen  in  the  clubbed  fingers  and  toes  which  these  children  pre- 
sent. The  last  phalanges  become  enlarged  and  thick,  and  the 
nails  somewhat  deformed.  Dyspnoea,  increased  on  exertion, 
is  a  marked  symptom  and  is  always  troublesome.  Dropsy  in 
the  limbs  and  serous  membranes  may  supervene. 

Diagnosis :  In  the  presence  of  cyanosis  and  a  murmur  the 
diagnosis  is  made.  In  the  absence  of  a  murmur  other  causes, 
which  are  mainly  pulmonary,  of  cyanosis  must  be  excluded. 
Nothing  more  than  a  guess  as  to  the  variety  of  abnormality 
in  the  heart  can  be  made. 

Prognosis :  This  is  bad.  Most  of  the  cases  die  before  they 
are  twenty,  and  during  their  life  they  are  in  a  state  of  con- 
tinual danger  and  discomfort.  Their  functions  are  badly  per- 
formed, they  are  delicate,  and  bear  badly  any  acute  disease, 
particularly  in  the  respiratory  system.  The  more  marked  the 
cyanosis  the  worse  the  prognosis. 

Congenital  heart-disease — treatment :  There  is  nothing  to 
do  for  the  abnormalities  themselves.  Good  hygiene  and  pre- 
vention of  colds  and  exertion  are  necessary.  Otherwise  we 
can  only  treat  symptoms  as  they  arise. 


ACUTE  PERICARDITIS.  181 


ACUTE  PERICARDITIS. 


Etiology :  This  is  a  quite  rare  disease  in  infancy,  but  is  as 
common  in  older  children  as  in  adults.  The  principal  cause  is 
rheumatism.  It  may  complicate  pneumonia,  or  pleurisy,  or 
scarlet  fever.  General  sepsis  may  involve  the  pericardium. 
Direct  injury  and  extension  of  the  inflammation  from  a 
neighboring  organ  are  frequent  causes. 

Pathology :  The  pericardium  may  be  the  seat  of  a  dry 
inflammation  in  which  the  membrane  is  swollen  and  rough  and 
coated  with  fibrin  ;  or,  more  commonly,  there  is  at  the  same 
time  an  effusion  of  serum  in  greater  or  less  quantity  in  the  sac. 
In  children  the  serous  variety  is  commoner  than  in  adults. 
In  other  cases  there  is  a  distinct  purulent  character  to  this 
effusion.  Rarely  it  is  hemorrhagic.  After  recovery  the 
fluid  is  absorbed,  but  the  fibrin  becomes  organized,  leaving 
adhesions  between  the  two  layers  of  pericardium. 

Acute  pericarditis — symptoms:  The  subjective  symptoms 
are  few  and  slight.  There  may  be  a  little  precordial  pain, 
and  some  interference  with  the  heart's  action.  If  effusion 
embarrasses  the  heart,  there  may  be  some  dyspnoea  and  a  weak, 
irregular  pulse.  The  other  symptoms  are  those  of  the 
primary  disease.  Pericarditis  lasts  usually  two  or  three 
weeks. 

Acute  pericarditis — physical  signs :  In  dry  pericarditis 
there  is  heard  a  superficial  to-and-fro  friction-sound  directly 
over  the  heart  and  uninfluenced  by  inspiration.  It  is  loudest 
in  the  third  and  fourth  spaces  just  to  the  left  of  the  sternum. 

In  the  serous  variety  the  area  of  cardiac  dulness  is  increased 
in  all  directions,  this  dulness  extending  further  to  the  left 
than  the  apex-beat,  There  is  usually  a  small  area  of  dul- 
ness extending  to  the  right  of  the  sternum.  The  heart- 
sounds  are  heard  feebly,  and  a  preceding  friction-sound  will 
disappear. 

Diagnosis :  This  depends  entirely  on  the  physical  exami- 
nation of  the  heart.  The  use  of  an  exploring-needle  to  cor- 
roborate the  diagnosis  of  effusion  and  to  decide  on  the  kind 
of  fluid  present  is  always  allowable. 

Prognosis:    The  younger    the   child   the  more    serious  the 


182  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

prognosis.  While  pericarditis  is  always  a  serious  disease, 
and  always  adds  a  bad  element  to  the  condition  which  it 
complicates,  still  it  is  frequently  recovered  from.  The  pres- 
ence of  fluid  aggravates  the  danger  as  it  increases  in  quantity. 
Purulent  pericarditis  is  the  most  dangerous  form.  The 
adhesions  left  after  recovery  are  often  the  source  later  of 
serious  trouble. 

Acute  pericarditis — treatment :  Absolute  rest  in  bed  should 
be  enforced  from  the  first.  Locally,  hot  applications,  or 
mild  counter-irritation,  or  an  ice-bag  with  a  layer  of  flannel 
between  it  and  the  skin,  seem  to  have  some  power  of  limiting 
the  inflammation. 

The  diet  should  be  easily  digestible  and  in  moderate  quan- 
tity, so  as  not  to  overload  the  stomach.  The  primary  disease 
to  which  the  pericarditis  is  secondary  should  be  treated 
thoroughly.  Probably  the  best  drug  to  use  is  opium  to  quiet 
the  patient  and  the  heart.  Aconite  or  digitalis  may  be  used 
to  slow  an  overacting  heart.  The  latter  is  especially  good  if 
the  heart's  action  becomes  feeble. 

If  effusion  is  present,  counter-irritation  and  some  diuretic, 
as  caffeine,  will  usually  remove  it.  If  it  is  persistent  and 
interferes  with  the  heart  by  its  mechanical  presence,  aspira- 
tion done  in  the  fifth  intercostal  space  just  to  the  left  of  the 
sternum  is  advisable.  If  the  effusion  is  purulent,  it  is  best 
removed  by  incision. 

After  the  attack  is  over  renewal  of  physical  exertion 
should  be  gradual,  and  tonic  treatment  is  indicated. 

CHRONIC  PERICARDITIS. 

Pathology :  This  condition  is  mainly  the  result  of  one  or 
more  attacks  of  acute  pericardial  inflammation.  At  times 
it  is  tubercular. 

The  main  lesions  are  a  thickening  of  the  pericardium  and 
the  presence  of  permanent  connective-tissue  adhesions  be- 
tween the  visceral  and  parietal  layers. 

Symptoms :  There  are  usually  no  subjective  symptoms, 
unless  some  feeling  of  interference  about  the  heart  and 
dyspnoea  on  exertion. 


ACUTE  ENDOCARDITIS.  183 

Chronic  pericarditis — physical  signs :  The  heart  is  usually 
enlarged,  the  apex  being  displaced  to  the  left  and  downward. 
The  only  characteristic  sign  is  retraction  of  a  small  spot  of 
the  chest-wall  during  the  systole  of  the  heart.  This  is  pres- 
ent, though,  in  but  a  small  percentage  of  the  cases. 

Prognosis  :  The  lesion  is  permanent,  but  is  compatible  with 
long  life. 

Chronic  pericarditis — treatment :  There  is  no  special  treat- 
ment for  the  disease.  Good  hygiene  and  attention  to  the 
body-functions  comprise  the  therapeutics. 

ACUTE  ENDOCARDITIS. 

Inflammation  of  the  endocardium,  especially  that  part  enter- 
ing into  the  formation  of  the  valves,  is  quite  as  frequent  in 
childhood  as  in  adult  life.  In  foetal  life  usually  the  right 
heart  is  affected  ;  after  birth  the  left  heart,  as  in  adults. 

Etiology :  Rheumatism  is  the  most  frequent  cause  of  the 
disease.  Scarlet  fever,  septicaemia,  and,  less  frequently,  the 
other  infectious  diseases,  are  complicated  by  endocarditis. 

Pathology  :  The  endocardium  is  swollen  only  and  remains 
smooth,  or  there  is  an  extensive  growth  of  new  connective- 
tissue  cells  in  its  substance.  This  produces  warty  excres- 
cences on  the  surface  of  the  endocardium  involved,  and  on 
these  excrescences  fibrin  coagulates  from  the  blood  and 
organizes,  exaggerating  the  changes.  The  valve  becomes 
deformed,  the  chordae  tendinese  shortened,  and,  the  new  con- 
nective tissue  being  deficiently  vascularized,  tends  to  break 
down  and  ulcerate.  Portions  of  these  "vegetations,"  as 
they  are  called,  may  be  broken  off  and  carried  by  the  blood- 
current  to  different  parts  of  the  body,  where  they  lodge,  and 
are  called  emboli.  The  vessel  in  which  they  are  caught  is 
stopped  up,  and  the  process  is  called  embolism. 

Acute  endocarditis — symptoms :  There  may  be  no  rational 
symptoms  at  all,  or  the  endocarditis  may  show  itself  by  some 
fever,  malaise,  disturbed  heart-action,  and  restlessness.  The 
pulse  is  usually  rapid  and  not  very  strong,  and  there  may  be 
venous  congestion  of  the  body  with  dyspnoea.  Delirium 
or  stupor  may  be  present. 


184         DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

At  times  the  signs  of  an  embolism  in  some  portion  of  the 
body  is  the  first  symptom,  suggesting  a  heart-lesion.  If  the 
embolus  goes  to  the  brain,  hemiplegia  is  the  usual  result ;  to 
the  lungs,  sharp  dyspnoea  ;  to  the  kidneys,  haematnria ;  to  the 
liver  and  spleen,  local  pain  and  enlargement ;  to  the  mesen- 
tery, diarrhoea  ;  to  the  limbs,  obstructed  circulation. 

An  attack  of  acute  endocarditis  lasts  two  or  three  weeks, 
and  ends  in  recovery  or  death,  or  often  becomes  the  starting- 
point  for  a  chronic  endocarditis. 

Acute  endocarditis — physical  signs  :  Regular  physical  ex- 
amination of  the  heart  will  often  show  the  presence  of  an 
acute  endocarditis  during  an  attack  of  rheumatism  or  scarlet 
fever  when  no  subjective  symptoms  of  any  kind  are  present. 
The  physical  signs  depend  on  the  changes  in  the  valves — in- 
sufficiency, or  roughening,  or  stenosis.  According  to  the 
valve  involved,  and  the  lesion  of  this  valve,  will  be  the  form 
of  murmur  present. 

With  mitral  regurgitation  we  hear  a  systolic  murmur,  loud- 
est over  the  apex  ;  with  mitral  stenosis,  a  presystolic  murmur, 
heard  loudest  over  the  mitral  area ;  with  aortic  regurgitation, 
a  diastolic  murmur,  heard  over  the  aortic  valve  and  carried 
down  the  sternum  ;  with  aortic  roughening,  a  systolic  murmur, 
heard  loudest  over  the  aortic  valve.  The  valves  of  the  right 
side,  and  combinations  of  valves,  give  their  distinct  murmurs 
also. 

Diagnosis :  This  depends  on  the  physical  signs  rather  than 
on  the  symptoms.  Pericarditis  is  differentiated  by  its  friction- 
sound,  which  is  superficial  and  not  connected  with  valvular 
closure.  Functional  or  anaemic  murmurs  are  at  times  diffi- 
cult to  exclude.  They  may  be  heard  over  the  apex,  but  are 
most  frequent  over  the  pulmonary  valve — the  second  left  in- 
terspace. The  second  pulmonic  sound  will  not  be  accentu- 
ated in  anaemic  murmurs.  An  old  valvular  lesion  being 
present  and  not  before  recognized,  may  raise  the  suspicion  of 
an  acute  endocarditis  when  none  exists. 

Prognosis :  Recovery  without  some  change  left  behind  in 
the  valves  is  rare,  but  at  times  all  murmurs  and  all  evident 
signs  of  heart-lesion  do  disappear  permanently.  In  some 
cases  the  valves  remain  without  undergoing  further  change 


MALIGNANT  ENDOCARDITIS.  185 

throughout  life.  In  others,  slow  changes  continue  and  the 
case  becomes  one  of  chronic  endocarditis.  Recurrent  attacks 
are  common.     Very  few  die  in  the  acute  stage. 

Acute  endocarditis — treatment :  If  any  suspicion  of  a  rheu- 
matic diathesis  is  present,  anti-rheumatic  treatment  should  be 
instituted.  The  salicylates,  combined  with  the  citrate  of 
potassium,  in  large  enough  doses  to  render  the  urine  alkaline,  is 
the  best  form  to  give  this.  Absolute  rest  in  bed  is  of  primary 
importance.  If  the  heart's  action  is  exaggerated  and  tumul- 
tuous, aconite  or  opium  is  indicated  to  quiet  it.  If  the 
heart's  action  is  feeble  and  rapid,  digitalis  is  the  best  drug. 

After  the  acute  stage  has  passed,  rest  should  be  insisted  on 
for  some  time,  and  exertion  should  be  resumed  very  grad- 
ually. Iron  and  tonics  are  to  be  used  freely  during  this 
stage.  Efforts  should  be  made  to  prevent  subsequent  attacks 
of  rheumatism  in  these  patients. 

MALIGNANT  ENDOCARDITIS. 

This  is  often  called  ulcerative  endocarditis,  and  in  childhood 
occurs  most  always  after  the  tenth  year.  Hence  it  differs  in 
no  respect  from  the  same  condition  when  seen  in  adults. 

Etiology  :  The  disease  is  a  cardiac  sepsis,  combined  with  an 
inflammation  of  the  endocardium.  It  occurs  with  rheuma- 
tism, pneumonia,  erysipelas,  scarlet  fever,  gonorrhoea,  and 
septicaemia.  Streptococci,  staphylococci,  and  pneumococci  are 
found  in  the  endocardium.  Probably,  it  is  never  a  primary 
condition. 

Pathology :  The  endocardium  is  swollen,  infiltrated  with 
round  cells,  and  often  ulcerated.  The  surface  is  coated,  in 
patches,  with  a  thin  or  thick  layer  of  fibrin  and  micrococci. 
Vegetations  and  ulcerations  form  in  the  cavities  and  on  the 
valves.  Portions  of  these  vegetations  being  detached  are  car- 
ried by  the  blood  to  distant  parts  of  the  body  and  lodge  as 
emboli,  causing  not  only  the  mechanical  results  of  embolism, 
but  setting  up  an  infectious  inflammation  at  the  same  spot. 

Malignant  endocarditis — symptoms :  The  disease  is  very 
irregular  in  its  symptomatology,  and  really  presents  nothing 
characteristic.     The  symptoms  are  those  of  a  genera/  septicoe- 


186  DTSEASES  OF  THE  CIRCULATORY  SYSTEM. 

mia.  Fever  of  an  irregular  variety  and  often  quite  high,  ac- 
companied by  an  occasional  chill,  is  regularly  present.  Fre- 
quent sweats,  marked  prostration,  anorexia,  vomiting,  and 
diarrhoea,  are  usually  found.  The  so-called  typhoid  state 
develops  rather  rapidly,  with  dry  tongue,  sordes  on  the  lips, 
rapid  emaciation  and  alternating  stupor  and  delirium.  Pete- 
chial eruptions  and  the  signs  of  embolism  in  various  parts  of 
the  body  may  exist.  The  heart  and  pulse  may  not  be  much 
disturbed,  or  may  be  rapid  and  feeble,  or  may  be  irregular. 
Dyspnoea,  more  or  less  marked,  may  supervene.  The  disease 
lasts  from  a  week  to  ten  days  in  the  more  rapid  cases,  to  a 
month  in  the  slower  ones.     Death  is  usually  due  to  exhaustion. 

The  physical  signs  of  malignant  endocarditis  depend  on 
the  development  of  a  murmur.  This  murmur  is  most  apt  to 
be  that  of  mitral  insufficiency.  Aortic  regurgitation  may 
develop  with  its  characteristic  murmur.  In  some  cases  no 
murmur  may  be  detected,  when  after  death  there  may  be 
marked  evidence  of  valvular  disease.  The  spleen  is  regularly 
enlarged.     Albuminuria  may  be  present. 

Diagnosis :  The  presence  of  symptoms  of  septicaemia  or 
pyaemia,  together  with  a  heart-murmur,  are  the  points  for 
diagnosis.  Typhoid  fever  and  general  tuberculosis  are  to  be 
differentiated  by  their  special  symptoms.  In  many  cases  the 
diagnosis  is  impossible,  but  the  possibility  of  malignant  endo- 
carditis in  all  obscure  cases  of  a  septic  type  must  be  remem- 
bered. 

Prognosis :  This  is  almost  uniformly  fatal. 

Malignant  endocarditis — treatment :  Nothing  more,  can  be 
done  than  to  nourish  the  patient  properly  and  to  use  alcoholic 
stimulants. 

CHRONIC  ENDOCARDITIS. 

Definition :  This  is  a  slowly  developing,  insidious  disease, 
usually  leading  to  marked  deformities  of  the  valves  of  the 
heart. 

Etiology:  Rheumatism  is  the  most  frequent  etiological 
factor.  Many  of  the  cases  are  secondary  to  acute  endocar- 
ditis. Some  cases  develop  during  scarlet  fever  or  chorea. 
Syphilis  is  at  times  a  cause. 


CHRONIC  ENDOCARDITIS.  187 

Pathology :  The  inflammation  involves  oftenest  the  endo- 
cardium of  the  mitral  or  aortic  valves.  The  endocardium  of 
the  tricuspid  or  pulmonary  valves,  or  of  the  ventricles  or 
auricles,  is  less  often  affected.  The  endocardium  is  thickened 
by  the  infiltration  of  new  cells  and  the  growth  of  new  con- 
nective tissue  in  its  substance.  Little  beaded  vegetations 
may  form  on  its  surface,  thickening  and  roughening  the  valves. 
In  other  cases  the  surface  of  these  vegetations  becomes 
ulcerated  and  roughened,  and  thrombi  form  on  them  or  lime- 
salts  are  deposited  in  them.  These  changes  occurring,  as 
they  do,  most  markedly  in  the  neighborhood  of  the  valves, 
cause  them  to  be  contracted,  thickened,  and  deformed.  After 
this  the  valves  cannot  be  opened  or  closed  properly,  and  this 
causes  stenosis  or  insufficiency  of  the  valvular  opening. 

In  insufficiency  the  valves  cannot  be  shut  properly,  and 
some  blood  is  forced  back  by  the  contraction  of  the  heart. 
In  stenosis  the  valvular  opening  is  so  small  that  the  blood  is 
pumped  through  it  with  difficulty.  More  than  one  form  of 
lesion  may  be  present  at  the  same  time. 

Complicating  lesions  are  always  present :  dilatation  of  the 
ventricles,  hypertrophy  of  their  walls,  and  disturbances  in 
the  circulation  in  other  organs  of  the  body.  Due  to  this 
venous  obstruction,  we  get  congestion  of  the  lungs,  liver, 
spleen,  and  brain.  Dropsy  of  the  serous  cavities  and  of  the 
subcutaneous  tissues  is  also  often  found. 

Chronic  endocarditis — symptoms  :  The  pathological  changes 
take  place  so  slowly,  and  the  interference  with  the  valvular 
action  is  so  gradual,  that  the  heart-muscle  accommodates  itself 
to  the  extra  work  required  to  pump  the  blood  with  the  valves 
diseased.  This  accommodation  of  the  heart  is  called  compen- 
sation  and  lasts  up  to  a  certain  point  only,  after  which  the 
compensation  is  lost  and  the  heart  becomes  unable  to  perform 
its  functions  in  full. 

During  the  time  of  full  compensation  there  are  virtually 
no  symptoms  from  the  endocarditis,  and  often  the  discovery 
of  a  murmur  is  the  first  intimation  the  patient  has  of  any 
trouble  with  his  heart.  This  condition  of  compensation  may 
last  many  years,  or  may  give  way  in  a  short  time.  Much 
depends  on  the  endocarditis  becoming  stationary  or  advanc- 


188  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

ing,  and  on  the  general  condition  of  health  and  the  habits  of 
life  of  the  patient.  Marked  deformities  of  the  valves,  acute 
illness,  or  chronic  malnutrition,  or  excessive  muscular  exertion 
tends  to  destroy  compensation. 

Usually  the  earliest  symptom  of  chronic  valvular  disease 
is  dyspnoea  on  exertion,  and  this  may  be  present  even  during 
fair  compensation.  Palpitation  of  the  heart  may  be  felt  at 
times,  but  is  not  constant.  Pain  around  the  heart  is  rare. 
As  compensation  begins  to  fail  the  rational  symptoms  of  the 
disease  appear.  They  are  mainly  due  to  venous  congestion 
of  the  various  tissues  of  the  body.  In  the  brain  the  conges- 
tion produces  headache,  vertigo,  stupor,  delirium,  at  times 
convulsions ;  in  the  lungs,  dyspnoea,  orthopnoea,  cough, 
haemoptysis,  chronic  bronchitis,  the  pneumonia  of  heart-dis- 
ease, and  oedema  of  the  lungs  ;  in  the  pleural  cavity,  hydro- 
thorax  ;  in  the  stomach  and  intestines,  indigestion,  vomiting, 
at  times  hsematemesis ;  in  the  liver,  enlargement  and  func- 
tional disturbances ;  in  the  peritoneum,  effusion  ;  in  the  kid- 
neys, scanty  urine  and  albuminuria ;  in  the  limbs,  dropsy. 
The  pulse  is  usually  rapid,  feeble,  and  often  irregular.  It 
has  different  characteristics  in  different  lesions  of  the  valves, 
which  are  described  under  physical  signs.  Emboli  from  the 
heart  may  be  carried  to  any  part  of  the  body,  and  produce 
their  characteristic  symptoms  there  :  in  the  brain,  paral- 
ysis ;  in  the  lungs,  dyspnoea ;  in  the  mesentery,  bloody 
stools ;  in  the  spleen  or  liver,  pain  ;  in  the  kidneys,  hema- 
turia ;  in  the  limbs,  thrombosis  and  oedema.  The  symptoms 
gradually  increase  in  severity  until  death,  or  periods  of 
greater  or  less  improvement  occur,  to  be  followed  by  a  re- 
turn of  the  symptoms  later.  The  disease  may  last  for  many 
years. 

Chronic  endocarditis — physical  signs :  These  depend  on  the 
valve  affected.  In  aortic  stenosis,  which  is  the  rarest  lesion 
of  the  left  heart,  a  systolic  murmur  is  heard  with  its  greatest 
intensity  over  the  second  right  intercostal  space  quite  near  to 
the  sternum,  and  is  transmitted  upward  into  the  great  ves- 
sels of  the  neck.  A  similar  murmur  is  caused  by  simple 
roughening  of  the  valves,  and  also  in  ansemia  ;  but  in  stenosis 
there  is  decided  hypertrophy  of  the  left  ventricle,  with  dis- 


CHRONIC  ENDOCARDITIS.  189 

placement  of  the  apex  to  the  left  and  downward.  The 
pulse  is  small  and  usually  regular. 

In  aortic  insufficiency  there  is  a  diastolic  murmur  heard 
loudest  over  the  sternum  at  about  the  level  of  the  third  rib, 
and  transmitted  down  the  sternum  and  to  the  apex.  The 
left  ventricle  is  greatly  hypertrophied  and  dilated.  The 
pulse  in  all  the  arteries  is  exaggerated,  and  distinct  throbbing 
is  present  in  the  larger  ones.  This  is  often  felt  quite  un- 
pleasantly by  the  patient.  The  pulse  on  palpation  is  quite 
characteristic,  and  is  called  "water-hammer,"  or  "  Corri- 
gan."  The  upstroke  is  very  sudden  and  the  collapse  equally 
so.  The  arteries  are  almost  empty  in  the  interval.  Raising 
the  arm  brings  out  the  characteristics  of  this  pulse. 

In  mitral  stenosis  a  presystolic  murmur  is  heard  over  a 
limited  area  directly  over  the  location  of  the  mitral  valve. 
This  murmur  is  not  transmitted.  On  palpation  a  distinct 
thrill  is  felt  with  each  systole  of  the  heart.  The  left  auricle 
and  right  ventricle  became  dilated  and  hypertrophied  in  this 
condition,  displacing  the  apex  to  the  left,  but  not  markedly 
downward.    The  pulse  is  small,  feeble,  and  apt  to  be  irregular. 

In  mitral  regurgitation  a  systolic  murmur  is  heard  with 
maximum  intensity  over  the  apex,  and  is  transmitted  around 
the  subaxillary  space  into  the  back.  The  second  pulmonic 
sound  is  accentuated.  The  left  ventricle  becomes  dilated 
and  hypertrophied.  The  pulse  is  small,  weak,  and  apt  to  be 
irregular. 

The  right-sided  lesions  are  rare  and  difficult  to  diagnose, 
but  tricuspid  insufficiency  may  develop  as  a  secondary  lesion 
to  mitral  valve  disease.  It  gives  a  systolic  murmur  heard 
mainly  over  the  ensiform  cartilage.  The  great  veins  of  the 
neck  are  apt  to  pulsate  with  the  systole  of  the  heart. 

Various  combinations  are  often  present,  giving  two  or 
more  murmurs  at  the  same  time. 

Chronic  endocarditis — diagnosis  :  This  depends  on  the  physi- 
cal signs.  The  only  thing  to  be  remembered  is  the  possibility 
of  the  murmurs  being  functional.  No  functional  murmurs 
have  associated  the  changes  of  hypertrophy  and  dilatation, 
which   nre    present    with    actual    valvular  disease. 

Prognosis:   On   the  whole,  the  prognosis  in  children  is  not 


190         DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

so  good  as  in  adults.  At  the  time  of  puberty,  particularly, 
the  extra  strain  put  on  the  heart  is  apt  to  destroy  compensa- 
tion. Aortic  stenosis  and  mitral  insufficiency  are  the  least 
serious  varieties  of  endocarditis.  Mitral  stenosis  is  the  more 
serious,  and  aortic  insufficiency  the  most  serious  of  all. 
Absolute  recovery  from  the  disease  is  exceedingly  rare,  and 
the  presence  of  endocarditis  always  increases  the  danger  from 
attacks  of  other  diseases.  Long  life  is  compatible  with 
valvular  lesions  under  some  circumstances. 

Chronic  endocarditis — treatment :  If  compensation  is  present, 
all  treatment  directed  to  the  heart  is  useless.  During  this 
period  the  patient's  general  hygiene  should  be  carefully  under 
regulation.  The  diet  should  be  varied  and  easily  digestible, 
and  moderated  outdoor  exercise  should  be  carried  out,  with 
avoidance  of  all  great  and  sudden  strain.  Daily  bathing, 
proper  sleeping,  and  regulation  of  the  bowels  are  important. 
Measures  should  be  taken  to  prevent  all  forms  of  acute  dis- 
ease, especially  rheumatism  and  the  infections.  The  child's 
nutrition  should  be  particularly  watched,  and  iron,  cod-liver 
oil,  and  tonics  given  if  there  are  evidences  of  anaemia  or  mal- 
nutrition. 

If  compensation  fails,  then  is  the  time  for  treatment  directed 
to  the  heart  proper.  The  first  and  most  important  factor  in 
this  is  absolute  rest  in  bed  for  a  considerable  length  of  time. 
This  at  once  makes  the  work  of  the  heart  much  less,  and 
allows  it  to  recover  its  strength.  Combined  with  this,  the 
drug  of  most  value  is  digitalis.  It  should  be  given  alone  if 
the  arteries  are  soft ;  and  should  be  used  with  nitroglycerin, 
or  chloral,  or  iodide  of  potassium,  if  the  arteries  are  tense.  At 
the  same  time  the  general  venous  congestion  is  reduced  by 
diuretics  and  saline  purges,  either  of  which  class  of  drugs 
removes  much  water  from  the  system.  The  diet  had  best 
be  reduced  to  milk  only  for  a  time  during  this  stage.  As 
the  heart  improves,  return  to  solid  and  highly  nourishing  diet, 
and  the  use  of  strychnine  and  iron  are  indicated. 

The  special  symptoms  as  they  arise  require  special  treat- 
ment. Dropsy  of  the  serous  cavities  may  be  removed  by 
diuretics  and  purges ;  but  tapping  may  be  necessary.  The 
oedema  of  the  limbs  had  best  not  be  interfered  with  surgically 


ACUTE  MYOCARDITIS.  191 

from  the  danger  of  infection.  Intense  dyspnoea  and  orthop- 
noea  are  relieved  by  nitroglycerin  and  opium.  Sleeplessness 
is  relieved  by  trional. 

ACUTE  MYOCARDITIS. 

Definition:  This  is  an  inflammation  of  the  muscular  wall 
of  the  heart. 

Etiology :  It  is  secondary  to  the  infectious  diseases — diph- 
theria, scarlatina,  typhoid  fever,  and  septicaemia.  It  is  rather 
commoner  in  children  than  in  adults.  Some  cases  are  asso- 
ciated with  pericarditis,  and  others  with  endocarditis. 

Pathology :  The  inflammatory  changes  may  be  diffuse  or 
circumscribed,  and  may  be  interstitial  or  parenchymatous. 
In  the  interstitial  form  the  heart-wall  is  infiltrated  with 
inflammatory  products,  round  cells,  sero-fibrin,  and  even 
blood-cells.  At  times  the  process  may  be  so  intense  in  spots 
as  to  form  a  small  abscess.  The  heart  is  flabby  and  softened, 
and  of  a  mottled  yellowish  color. 

In  the  parenchymatous  form  there  is  a  distinct  fatty  degen- 
eration of  the  muscle-fibers.  The  two  varieties  are  apt  to  be 
associated  at  the  same  time  in  the  same  heart.  These  hearts 
are  regularly  dilated. 

Acute  myocarditis — symptoms :  There  are  no  typical  symp- 
toms or  physical  signs  of  this  disease.  The  heart's  action 
may  be  too  slow  or  too  rapid,  or  feeble  or  irregular. 

The  attacks  of  cardiac  failure,  slow  or  rapid,  coming  on  in 
the  course  of  the  acute  infections  are  apt  to  be  due  to  this 
disease.  The  physical  signs  depend  entirely  on  the  enlarge- 
ment of  the  heart  from  the  dilatation. 

Diagnosis  :  It  is  impossible  to  make  a  sure  diagnosis.  The 
association  of  these  symptoms  with  one  of  the  infectious 
diseases  makes  the  diagnosis  probable. 

Prognosis  :   Recovery  is  possible,  but  death  is  the  rule. 

Acute  myocarditis — treatment:  Careful  nursing,  absolute 
rest,  and  proper  nourishment  during  the  course  of  an  infec- 
tious disease  tend  to  prevent  this  condition  from  developing. 
Strychnine  by  mouth  or  hypoderraatically  is  the  best  drug 
we  have  for  use  in  this  disease.     It  should  be  used  in  large 


192         DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

doses,  and  often  up  to  the  physiological  limit.  In  imminent 
cases  hypodermatics  of  some  rapidly  diffusible  stimulant,  such 
as  ether,  brandy,  or  camphor,  are  useful.  Iron  and  tonics 
are  needed  during  convalescence. 

CARDIAC  NEUROSES. 

These  are  rather  rare  in  children,  as  most  of  the  causative 
factors  are  usually  the  developments  of  adult  life. 

Etiology :  Gastro-intestinal  disorders  are  the  commonest 
provoking  cause  of  these  neuroses.  A  neurotic  heredity  is 
usually  present.  Sudden  fright,  grief,  and  other  emotions 
may  cause  them.  The  early  use  of  tobacco  in  excess,  as  in 
cigarettes,  and  the  use  of  tea  and  coffee  are  other  causes. 
Anosmia  and  malnutrition  are  often  present. 

Pathology :  There  is  no  known  lesion  present  in  these  con- 
ditions. They  are  undoubtedly  due  to  some  reflex  influence 
acting  on  the  nervous  supply  of  the  heart.  Possibly  the 
absorption  of  toxins  from  the  digestive  tract  may  explain  the 
functional  derangements. 

Cardiac  neuroses — symptoms  :  These  are  palpitations,  irregu- 
larities in  rhythm,  excessively  rapid  or  slow  rate,  and  attacks 
of  syncope.  Respiration  is  liable  to  be  hurried  along  with 
the  change  in  the  heart-rate.  Normally  in  children  some 
irregularity  of  the  heart's  rhythm  is  fairly  common,  and 
occasions  no  disturbance.     Especially  is  this  so  during  sleep. 

Most  of  these  conditions  are  paroxysmal.  They  come  on 
in  attacks  lasting  a  short  time,  and  disappear  equally  quickly. 
The  physical  examination  of  the  heart  in  these  cases  is  nega- 
tive other  than  to  show  its  rate  and  rhythm. 

Diagnosis :  The  only  point  in  diagnosis  is  absolutely  to 
exclude  all  forms  of  organic  heart-disease,  pericardial,  endo- 
cardial, and  myocardial.  This  in  some  cases  can  be  done 
only  after  repeated  careful  examinations  of  the  heart,  and 
observation  of  the  child  for  some  time. 

Prognosis :  This  is  good.  The  neuroses  are  never  fatal  in 
the  attack,  and  with  proper  treatment  and  removal  of  the 
cause  the  tendency  to  the  attacks  can  be  cured.  Certain  cases 
with  marked  hereditary  predisposition  are  least  amenable  to 
treatment. 


CHRONIC  ENDARTERITIS.  193 

Cardiac  neuroses — treatment :  The  cause  should  be  care- 
fully searched  for  and  removed.  Gastro-intestinal  derange- 
ments should  be  corrected.  Attention  to  the  diet  is  of  great 
importance.  Tea,  coffee,  and  tobacco  should  be  stopped. 
Proper  exercise,  fresh  air,  and  regular  sleeping  hours  should 
be  enforced.  If  the  child  is  at  school,  supervision  of  its 
studies  should  be  undertaken.  Anaemia  and  malnutrition 
should  be  treated  in  the  usual  manner. 

During  attacks  digitalis,  strophanthus,  aromatic  spirits  of 
ammonia,  valerian,  and  the  bromides  are  the  most  useful 
drugs.  Between  attacks  no  special  treatment  for  the  heart 
proper  is  indicated. 


DISEASES  OF  THE  ARTERIES  AND  VEINS. 

CHRONIC  ENDARTERITIS. 

Inflammations  of  the  arteries  are  rare  in  children,  as  they 
are  regularly  the  result  of  senile  changes. 

Etiology :  Syphilis  or  tuberculosis  is  the  usual  cause. 

Pathology :  The  arterial  wall  undergoes  hyperplastic  in- 
flammation and  a  subsequent  degeneration  of  the  new  tissue, 
with  weakening  and  giving  way  of  the  wall. 

Chronic  endarteritis — symptoms:  The  development  of  an 
aneurism  in  this  weakened  wall  is  the  typical  symptom  of  this 
condition  in  children.  Aneurisms  are  quite  rare,  but  they 
have  been  found  in  the  abdominal  aorta,  the  iliac,  femoral, 
and  cerebral  arteries.  The  presence  of  a  pulsating  tumor  in 
the  line  of  an  artery  over  which  a  systolic  bruit  is  heard  ;  and 
the  mechanical  symptoms  due  to  its  pressure,  are  the  regular 
sinus  of  the  disease.  Endarteritis  in  patches,  without  aneu- 
rism, can  scarcely  be  diagnosed. 

Prognosis:  This  is  bad,  as  the  disease  is  apt  to  appear  in 
subjects  in  bad  general  health. 

Chronic    endarteritis — treatment:    This    is   the  same  as   in 
adults.     Antisyphilitic  treatment  should  be  used  in  the  pres- 
ence of  a  specific  history.     Surgical   intervention  in  external 
aneurism  is  always  advisable. 
13— d.  c. 


194         DISEASES   OF  THE  CIRCULATORY  SYSTEM. 

ACUTE  PHLEBITIS. 

Definition :  This  is  an  acute  inflammation  of  the  walls  of  a 
vein. 

Etiology:  Injury  of  the  vein,  extension  of  inflammation 
from  neighboring  structures,  the  presence  of  an  infective 
embolus,  and  exposure  to  cold  act  as  actual  causes.  It  also 
complicates  the  infectious  diseases,  particularly  typhoid  fever 
and  septicsemia.  In  some  cases  anaemia  seems  to  be  the  only 
cause. 

Pathology :  The  wall  of  the  vein  is  the  seat  of  an  acute 
inflammation  with  swelling  and  infiltration  by  inflammatory 
products.  The  internal  surface  becomes  roughened,  and  the 
lumen  of  the  vein  diminished,  thus  favoring  coagulation  of 
the  blood  in  the  vein.  The  inflammation  may  be  so  intense 
as  to  cause  minute  abscesses  in  the  wall  of  the  vein.  Throm- 
bosis, or  clotting  of  the  blood  in  the  vein,  may  be  the  result 
or  the  cause  of  the  phlebitis. 

Acute  phlebitis — symptoms :  There  are  pain  and  tenderness 
along  the  course  of  the  affected  vein,  and,  if  it  is  a  superficial 
vein,  a  red  swollen  line  follows  its  course.  Thrombosis  of 
the  blood  inside  occurs,  and  the  parts  below,  that  are  drained 
by  this  vein,  are  swollen  and  oedematous.  There  are  usually 
slight  fever  and  some  general  malaise.  In  infective  cases 
abscesses  may  form  in  the  course  of  the  vein. 

The  disease  may  last  but  a  couple  of  weeks,  with  cessation 
of  the  inflammation,  absorption  of  the  thrombus,  and  return 
of  the  vein  to  normal ;  or  it  may  run  a  chronic  course,  and 
in  some  cases  the  vein  remain  permanently  blocked,  all  signs 
of  acute  inflammation,  however,  disappearing. 

Diagnosis :  In  the  veins  of  the  limbs  the  diagnosis  is  fairly 
easy,  and  rests  on  the  presence  of  signs  of  inflammation  over 
the  vein  and  thrombosis.  In  the  trunk  the  symptoms  are 
mainly  those  of  thrombosis  and  blocking  of  the  circulation, 
and  the  diagnosis  is  more  difficult. 

Prognosis  :  This  is  fairly  good  unless  the  disease  occurs  in 
the  veins  of  some  one  of  the  vital  organs,  as  for  instance  the 
brain,  or  unless  it  is  part  of  a  general  septic  process. 

Acute  phlebitis — treatment :  Rest  and  the  avoidance  of  all 


NMVUS,  195 

unnecessary  movement  in  the  part  containing  the  affected 
vein  are  of  primary  imj)ortance.  This  is  to  reduce  the 
chance  of  breaking  off  a  piece  of  the  clot,  and  the  formation 
by  it  of  an  embolus  elsewhere.  Hot  applications,  lead  and 
opium  wash,  and  in  the  chronic  stage  mild  counter-irritation, 
as  by  iodine,  assist  in  absorption  of  the  clot.  The  bowels 
should  be  kept  freely  open  and  the  patient  fed  on  nourishing 
diet.     No  drugs  are  of  any  special  value. 


DISEASES  OF  THE  CAPILLARIES. 

Definition  :  This  condition,  which  is  also  called  angioma,  is 
one  of  the  commonest  congenital  disfigurements  of  childhood. 

Etiology  :  Noevi  are  probably  always  congenital.  At  times 
they  may  be  so  small  at  birth  as  not  to  be  noticed,  and  then 
grow  distinctly  after  birth.  In  olden  times  they  were  erro- 
neously ascribed  to  maternal  impressions. 

Pathology :  There  are  two  general  varieties  :  the  capillary, 
with  a  great  increase  in  the  number  and  size  of  the  capilla- 
ries ;  and  the  cavernous,  in  which  there  is  a  form  of  erectile 
tissue,  the  blood  circulating  in  irregular  anastomosing  spaces 
without  distinct  vascular  walls. 

Nsevus — symptoms  :  When  superficial,  the  so-called  cuta- 
neous nrevus,  it  forms  the  well-known  port-wine  stain,  or 
"  mother's  mark."  These  are  purplish  blotches  on  the  skin  of 
irregular  shape  and  size.  They  may  be  situated  anywhere 
on  the  surface. 

In  the  subcutaneous  variety  there  is  a  soft,  irregular  tumor 
of  varying  size  under  the  skin.  It  is  increased  in  volume 
by  crying,  coughing,  or  exertion.  The  skin  over  it  may  be 
normal   or  bluish,  or  be   so  thin  that  the  tumor  shows  the 

bl 1  color  through  it.      Pressure  reduces  its  size,  but  it  fills 

again  on  removing  the  pressure. 

As  a  rule  no  other  symptoms  than  the  presence  of  a  mark 
or  a  tumor  arc  found  ;  but  in  certain  localities  pain,  or  the 
displacemenl  of  certain  organs,  may  be  caused  by  the  nsevus. 
This  is  seen,  for  instance,  in  the  orbit.      Hemorrhage,  which 


196         DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

may  be  dangerous,  may  occur  from  them.  They  are  most 
often  found  around  the  head  and  neck.  They  may  occur  in 
the  viscera,  as  the  liver,  spleen,  or  kidneys,  but  are  only 
diagnosed  at  autopsy. 

Diagnosis  :  The  cutaneous  form  is  simple.  The  subcutane- 
ous may  be  mistaken  for  other  tumors,  and  especially  for 
lipomata.  The  increase  in  size  on  exertion  and  decrease  on 
pressure  are  the  points  in  favor  of  nsevus. 

Prognosis  :  They  rarely  disappear  spontaneously.  Usually 
they  remain  stationary  and  are  only  disfigurements.  They 
may  grow,  however,  and  become  not  only  very  unsightly,  but 
even  disabling.     They  are  not  dangerous. 

Nsevus — treatment :  This  is  based  on  replacing  the  vascular 
tissue  by  cicatricial  tissue,  which  may  be  brought  about  by  the 
local  application  of  caustics,  the  actual  cautery,  or  electroly- 
sis. Diffuse  scarification  may  be  tried  in  large  port-wine 
stains.  In  the  subcutaneous  variety  any  of  the  above  meth- 
ods may  be  tried ;  or  injections  of  coagulating  fluids,  or  liga- 
tion by  passing  a  thread  around  the  tumor  and  strangling  it. 

DISEASES  OF   THE  BLOOD. 

The  blood  in  early  infancy :  During  the  first  week  or  two 
of  extra-uterine  life,  and  in  premature  infants,  the  blood 
differs  considerably  from  that  of  adults.  The  specific  gravity 
and  the  proportion  of  haemoglobin  are  high,  the  number  of 
red  cells  exceeds  the  normal  five  millions  per  cubic  millimetre, 
and  there  are  present  nucleated  erythrocytes  or  hsematoblasts 
in  considerable  numbers,  and  also  many  red  cells  with  the 
haemoglobin  dissolved  out. 

The  leucocytes  are  also  present  in  larger  number  than  the 
normal  ten  thousand  per  cubic  millimetre.  They  may  increase 
to  twenty  or  even  thirty  thousand.  In  other  words,  leucocy- 
tosis  is  a  normal  condition  during  this  stage. 

The  five  different  varieties  of  leucocytes,  small  mononu- 
clear cells,  large  mononuclear  cells,  mononuclear  cells  with 
nucleus  undergoing  transition,  polynuclear  neutrophile  cells, 
and  eosinophile  cells,  are  found  as  in  adult  blood,  and  in  ap- 
proximately the  same  proportions.     Within  a  short  time  all 


SIMPLE  ANEMIA.  197 

the  elements  gradually  take  on  the  proportions  of  adult  blood, 
except  that  for  a  year  or  two  the  haemoglobin  is  lower  than 
the  normal  100  per  cent,  of  adult  life.  Otherwise  the  blood 
in  childhood  differs  very  little  from  that  of  maturity. 

In  health,  within  certain  rather  definite  limits,  the  propor- 
tion of  the  different  constituents  remains  constant.  In  dis- 
ease, diminished  production  or  increased  destruction  of  one  or 
another  element  produces  marked  changes  in  their  relative 
proportions,  and  gives  us  our  only  means  for  the  classification 
of  diseases  of  the  blood. 

SIMPLE  ANEMIA. 

This  is  also  called  primary  anaemia,  and  when  it  occurs  in 
young  girls  about  the  time  of  puberty  it  is  called  chlorosis, 
from  the  greenish  appearance  produced  in  the  skin. 

Etiology  :  The  disease  is  commonest  in  girls  and  during  the 
second  decade  of  life.  Confining  occupations,  impure  air, 
lack  of  exercise,  improper  food,  and  constipation  all  act  -as 
causes.  The  last  probably  acts  through  absorption  of  poi- 
sonous substances  into  the  blood,  which  should  be  excreted 
with  the  stools. 

Pathology:  On  examining  the  blood  the  haemoglobin  is 
found  far  below  normal,  often  being  down  to  30  or  40  per 
cent.  The  red  cells  and  leucocytes  are  not  diminished.  In 
other  words,  each  red  cell  has  lost  a  certain  proportion  of  its 
haemoglobin. 

Simple  anaemia — symptoms :  The  patient  is  languid,  feeble, 
and  incapable  of  exertion.  There  are  headache,  dyspnoea  on 
exertion,  vertigo,  palpitation  of  the  heart,  attacks  of  syncope, 
constipation,  anorexia  or  capricious  appetite,  and  amenorrhoea, 
one  or  all  in  almost  every  case.  The  skin  and  mucous  mem- 
branes are  pale,  and  the  muscles  flabby,  but  the  subcutaneous 
fat  is  not  diminished.  The  disease  comes  on  gradually,  and 
without  treatment  lasts  an  indefinite  length  of  time. 

Simple  anaemia — physical  signs:  The  blood-changes  de- 
scribed under  pathology  are  most  important.  There  is  usually 
a  systolic  murmur  heard  over  the  heart,  with  its  maximum  in- 
tensity over  the  pulmonic  area,  although  it  may  be  loudesl  at 


198         DISEASES   OF  THE  CIRCULATORY  SYSTEM. 

the  apex.  There  is  a  loud  venous  hum  heard  over  the  great 
vessels  in  the  neck. 

Diagnosis  :  This,  in  the  presence  of  the  typical  symptoms, 
depends  on  the  blood-examination. 

Prognosis:  This  is  good.  It  is  not  a  fatal  disease,  and 
under  proper  treatment  recovery  is  rapid. 

Simple  anaemia — treatment:  The  treatment  is  very  simple 
and  very  satisfactory.  The  bowels  should  be  kept  open, 
daily  exercise  in  the  fresh  air  should  be  prescribed,  and  iron 
should  be  given  regularly.  Blaud's  pills,  grains  three  or  five, 
three  times  a  day  after  meals,  give  most  excellent  results. 
Other  forms,  as  the  tincture  of  the  chloride  or  the  bitter 
wine,  may  be  used  when  it  is  impossible  to  swallow  pills. 

SECONDARY  ANEMIA. 

Definition:  This  disease  is  not  due  to  any  fault  of  the 
blood-making  apparatus,  but  is  secondary  to  general  consti- 
tutional states  which  increase  the  normal  wear  and  tear  on 
the  blood. 

Etiology  :  It  is  a  common  disease  of  infancy  and  childhood, 
and  is  seen  complicating  and  after  such  conditions  as  rheu- 
matism, tuberculosis,  syphilis,  acute  and  chronic  digestive 
disorders,  rachitis,  hemorrhages,  the  infectious  diseases,  ne- 
phritis, prolonged  suppuration,  malaria,  marasmus,  improper 
food  and  insufficient  air,  prolonged  fevers,  and  malignant 
growths.  In  some  cases  very  rapid  bodily  growth  seems  to 
be  the  only  discoverable  cause. 

Pathology:  Aside  from  the  lesions  of  the  primary  disease, 
the  changes  in  the  blood  are  all  that  we  expect  to  find. 
There  is  a  moderate  decrease  in  the  quantity  of  haemoglobin 
and  in  the  number  of  red  cells  in  the  blood.  The  diminu- 
tion in  each  is  fairly  proportionate — that  is,  the  cells  are 
decreased  in  number,  and  those  that  are  left  behind  have  less 
than  their  proportion  of  haemoglobin.  The  decrease  is  sel- 
dom as  great  as  it  often  becomes  in  simple  anaemia.  There 
is  no  increase  in  the  leucocytes. 

Secondary  anaemia- — symptoms  :  It  is  difficult  to  separate 
the  symptoms  due  to  the  anaemia  from  those  of  the  primary 


PERNICIOUS  ANMMIA.  199 

disease.  The  skiu  and  mucous  membranes  are  pale  and 
blanched.  The  muscles  are  flabby.  The  extremities  are 
apt  to  be  cold.  There  are  disinclination  to  exertion,  dyspnoea 
on  motion,  attacks  of  palpitation  of  the  heart  and  of  syncope, 
poor  appetite,  general  restlessness,  and  disturbed  sleep.  The 
patients  tire  easily,  and,  if  old  enough,  complain  of  headache. 
Anaemic  heart-murmurs  are  often  present,  but  are  less  marked 
than  in  the  essential  form  of  the  disease. 

Diagnosis :  This  depends  on  the  blood-changes  shown  by 
examination  in  the  presence  of  one  of  the  primary  diseases. 
The  absence  of  any  primary  cause  would  point  to  a  simple 
anaemia:  The  proportionate  percentage  of  haemoglobin  and 
cells  in  the  two  diseases  differs  also. 

Prognosis  :  This  depends  entirely  on  the  primary  disease. 
The  anaemia  itself  is  not  a  cause  for  special  prognosis. 

Secondary  anaemia — treatment:  The  cure  of  the  primary 
disease  is  of  first  importance.  All  digestive  disturbances 
particularly  must  be  corrected.  Good  hygiene,  proper  food, 
and,  above  all,  fresh  air,  must  be  insisted  on.  The  drugs  of 
most  value  directly  to  increase  the  richness  of  the  blood  are 
iron  and  arsenic.  The  former  may  be  given  as  the  bitter 
wine,  the  syrup  of  the  iodide,  or  the  pepto-manganate ;  the 
latter  as  Fowler's  solution.  In  children  who  can  swallow 
pills,  Bland's  pill,  with  arsenic,  is  the  best  form.  Cod-liver 
oil  seems  to  assist  the  treatment  in  certain  cases. 

PERNICIOUS  ANEMIA. 

Definition  :  This  is  a  primary  disease  of  the  blood  which 
progresses  regularly  to  a  fatal  end. 

Etiology  :  No  real  cause  for  the  disease  is  known.  It  is  of 
rare  occurrence  in  childhood.  Late  researches  point  to  the 
fact  of  the  disease  being  due  to  an  increased  destruction  of 
the  red  blood-cells  in  the  liver,  which  may  be  brought  about 
by  the  presence  in  the  portal  blood,  fresh  from  the  intestinal 
tract,  of  some  tome  principles. 

Some  cases  arc  due  to  the  presence  of  the  anchylostoma  du- 
odenale  in  the  intestines.     Such  are  rare  in  this  country. 

Pathology:  There  is  a  fatly  degeneration  of  the  walls  of 


200         DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

the  heart,  of  the  hepatic  and  renal  cells,  and  of  the  walls  of 
the  arteries  and  capillaries.  The  blood  shows  a  marked 
diminution  in  the  red  cells  and  in  the  haemoglobin.  The 
cells  that  are  left  have  a  normal  proportion  of  haemoglobin, 
but  are  of  irregular  shapes  and  sizes,  and  often  are  nucleated. 
The  leucocytes  are  not  absolutely  increased,  although  they  are 
so  relatively  to  the  number  of  erythrocytes  present. 

Pernicious  anaemia — symptoms :  The  symptoms  develop 
slowly  and  insidiously.  The  skin  and  mucous  membranes 
become  pale,  and  later  lemon  tinted.  The  muscles  grow 
flabby  and  soft,  and  progressively  feeble.  The  disinclination 
to  exercise  is  most  marked.  There  are  palpitation  of  the 
heart,  dyspnoea  on  exertion,  attacks  of  syncope,  and  a  gradual 
muscular  and  mental  enfeeble  men  t.  The  functions  of  the 
stomach  and  intestines  are  weakened,  with  the  consequent 
symptoms  of  indigestion  and  malnutrition.  There  may  be 
hemorrhages  into  the  retina,  or  from  the  mucous  membrane 
of  the  nose,  mouth,  stomach,  or  intestines,  or  even  under 
the  skin. 

In  the  later  stages  subcutaneous  oedema  may  develop,  but 
without  albuminuria.  Irregular  fever  is  present  at  some  time 
in  the  disease.  A  fair  degree  of  nutrition — that  is,  of  sub- 
cutaneous fat — is  usually  retained.  Anaemic  heart-murmurs 
are  usually  present.  Toward  the  end  the  feebleness  becomes  so 
marked  that  the  patient  is  absolutely  bedridden.  The  cases 
regularly  last  some  time,  with  intervals  of  seeming  improve- 
ment. 

Diagnosis  :  This  depends  on  the  blood-examination  showing 
both  the  great  decrease  in  red  cells  and  haemoglobin,  and  the 
morphological  changes  in  the  erythrocytes.  By  this  means 
the  other  varieties  of  anaemia  are  differentiated ;  and  all  dis- 
eases of  other  organs  should  also  be  excluded. 

Prognosis  :  This  is  distinctly  bad,  although  periods  of  im- 
provement are  to  be  expected. 

Pernicious  anaemia — treatment :  Rest,  fresh  air,  a  highly 
nutritious  and  easily  digestible  diet,  and  minute  attention  to 
all  the  functions  of  the  stomach  and  intestine  are  very  im- 
portant. No  constipation  should  be  permitted.  The  only 
drug  from  which   any  help  can  be  expected  is   arsenic.     It 


LEUKEMIA.  201 

should  be  given  in  Fowler's  solution,  in  gradually  increasing 
doses,  until  full  tolerance  is  reached. 


LEUKEMIA. 

Definition  :  This  is  a  disease  of  the  blood,  characterized  by 
a  marked  increase  in  the  leucocytes;  a  diminution  in  the 
number  of  erythrocytes,  and  in  the  quantity  of  haemoglobin  ; 
enlargement  of  the  spleen  and  lymphatic  glands  ;  and  increase 
in  amount  of  the  marrow  of  the  long  bones.  With  the  leu- 
cocytosis,  which  is  always  present,  one  or  more  of  the  other 
organs — spleen,  glands,  and  marrow — may  be  involved. 

Etiology  :  Nothing  definite  on  this  point  is  known.  It  is 
seen  with  some  frequency  in  children,  and  even  in  infants, 
and  in  boys  more  often  than  in  girls.  In  some  cases  it  seems 
to  be  secondary  to  malaria,  or  syphilis,  or  trauma  over  the 
spleen,  or  at  times  to  starvation. 

Pathology :  The  essential  lesions  are  in  the  blood,  spleen, 
lymph-glands,  and-  bone-marron\  The  blood  is  lighter  col- 
ored than  normal,  and  in  advanced  cases  has  a  whitish  puru- 
lent appearance.  The  number  of  red  cells  and  the  amount 
of  haemoglobin  are  moderately  diminished.  The  leucocytes 
are  very  much  increased  in  numbers,  at  times  being  as  many 
as  the  erythrocytes.  This,  of  course,  occurs  in  extreme  cases 
only.  The  proportions  of  the  different  varieties  of  leucocytes 
present  vary  with  the  form  of  leukaemia  present.  In  the 
lymphatic  variety  the  small  mononuclear  cells  are  mainly  in- 
creased. In  the  spleno-medullary  variety  the  large  mono- 
nuclear cells  are  mainly  in  excess,  while  the  eosinophiles  are 
also  increased.  The  spleen  is  usually  much  enlarged,  the 
changes  being  mainly  those  of  a  simple  hypertrophy.  The 
lymphatic  glands  are  hypertrophied  in  various  parts  of  the 
body,  single  <»r  multiple  groups  being  involved.  These  again 
undergo  simply  a  hyperplasia  of  their  normal  tissue.  New 
lymphoid  tissue  in  the  form  of  tumors  may  grow  in  the  liver, 
kidnevs,  or  peritoneum.  The  marrow  of*  the  hones  is  hyper- 
trophied, it-  color  may  be  yellow  or  red,  and  both  its  cells  and 
stroma  are  regularly  involved. 

All  of  the  organs,  blood,  spleen,  gland-,  and  marrow,  may 


202         DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

be  involved  at  once,  or  only  the  blood  with  the  glands,  when 
it  is  called  lymphatic  leukaemia  ;  or  the  blood  with  the  spleen 
and  marrow,  when  it  is  called  spleno-medullary  leukaemia.  In 
any  variety  all  the  organs  are  usually  somewhat  involved, 
although  certain  ones  are  more  markedly  so. 

Leukaemia — symptoms :  The  disease  usually  begins  insid- 
iously, but  advances  rather  more  rapidly  in  children  than  in 
adults.  The  child  is  pale,  very  weak  and  feeble  ;  has  marked 
dyspnoea  and  attacks  of  fainting.  Hemorrhages  from  the 
various  mucous  membranes,  as  into  the  retina  or  under  the 
skin,  are  often  seen  quite  early.  These  bleedings  at  times 
may  be  large  enough  to  be  quite  serious.  Enlargement  of 
the  abdomen  from  the  hypertrophied  spleen  or  of  the  various 
superficial  or  deep  lymphatic  glands  soon  begins,  and  at  times 
is  the  earliest  symptom.  The  heart's  action  is  rapid  and 
feeble,  and  there  may  often  be  irregular  rises  of  temperature 
lasting  over  some  days.  There  may  be  pains  and  tenderness 
in  the  bones  from  the  changes  in  the  marrow. 

As  the  disease  progresses  extreme  feebleness,  subcutaneous 
dropsy,  headaches,  failing  sight,  diarrhoea,  and  hemorrhages 
gradually  bring  on  the  fatal  issue.  The  cases  last  from  a 
few  months  to  a  year. 

Diagnosis  :  This  is  based  on  the  blood-examination — that 
is,  the  increase  in  the  number  of  leucocytes  and  the  propor- 
tions of  the  different  varieties. 

Prognosis :  This  is  almost  absolutely  fatal,  although  a  few 
cases  of  recovery  have  been  reported. 

Leukaemia — treatment :  Rest,  a  highly  nourishing  diet,  and 
fresh  air  are  of  importance.  Arsenic  in  gradually  increasing 
doses  is  the  best  drug.  Iron  and  phosphorus  are  often  used 
as  adjuvants. 

PSEUDOLEUKEMIA. 

Definition  :  This  is  often  called  Hodgkin's  disease,  malig- 
nant lymphoma,  lymphatic  anaemia,  and  splenic  anaemia.  It 
is  characterized  by  anaemia  and  enlargement  of  the  lymphatic 
glands  of  the  body.  Often  the  spleen  is  enlarged  at  the  same 
time,  and  in  some  cases  the  spleen  is  involved  without  the 


PSEUDOLEUKEMIA.  203 

glands.  To  this  variety  the  term  splenic  ancemia  is  especially 
applicable. 

Etiology :  The  disease  is  more  frequent  in  boys  than  in 
girls.  Syphilis,  tuberculosis,  and  malaria  are  possible  predis- 
posing factors.  Local  traumatism  may  be  assigned  as  the 
beginning.     Very  little  is  known,  however,  of  the  causes. 

Pathology :  In  the  blood  the  red  cells  are  decreased  in 
number  and  the  haemoglobin  correspondingly  in  amount,  but 
the  white  cells  are  unaltered. 

One  or  more  groups  of  lymphatic  glands  are  enlarged. 
The  glands  are  simply  hypertrophied,  both  the  stroma  and 
the  cells  being  involved.  They  have  no  tendency  to  sup- 
purate uor  caseate.  The  glands  in  the  neck  or  axillse  are 
usually   first  involved. 

In  the  spleen  new  growths  of  lymphoid  tissue  are  often 
found.  These  may  cause  a  uniform  or  irregular  enlargement 
of  that  viscus.  Similar  growths  of  lymphoid  tissue  may  be 
found  in  the  liver,  kidneys,  and  other  organs,  but  much  less 
commonly  than  in  the  spleen.  The  marrow  of  the  bones  in 
rare  cases  may  be  involved  in  this  hyperplastic  growth. 

Pseudoleukaemia — symptoms  :  The  first  symptom  is  regu- 
larly an  enlargement,  without  known  cause,  of  some  set  of 
superficial  lymph-glands.  Those  in  the  neck  are  usually 
earliest  involved.  The  axillary  or  inguinal  glands  may  soon 
be  affected,  or  even  some  of  the  deeper  sets,  as  the  thoracic 
or  retroperitoneal. 

After  some  little  time  the  constitutional  symptoms  of  the 
disease  appear.  These  are  mainly  the  result  of  the  ansemia, 
such  as  pallor,  weakness,  palpitation  of  the  heart,  dyspnoea 
on  exertion,  fainting1  attacks,  vertigo,  and  disordered  diges- 
tion.  Later,  hemorrhages  from  the  mucous  membranes  and 
into  the  skin,  subcutaneous  oedema,-  fever,  and  marked  loss 
of  flesh  and  strength  develop.  Toward  the  end  nervous 
symptoms,  delirium,  coma,  or  general  convulsions  may 
occur. 

As  the  glands  grow  in  size  pressure-symptoms  become 
prominent.  In  the  neck  they  produce  dyspnoea,  dysphagia, 
and  interference  with  the  blood-vessels  or  pneumogastric 
nerves;  in  the  thorax  they  may  press  on  the  trachea,  oesoph- 


204         DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

agus,  or  descending  vena  cava ;  in  the  abdomen  they  may 
produce  jaundice  by  pressure  on  the  bile-duct,  or  ascites  by 
pressure  on  the  portal  vein,  or  oedema  of  the  lower  extremi- 
ties by  pressure  on  the  ascending  vena  cava ;  in  the  spleen  they 
produce  enlargement;  in  any  position  they  may  produce  pain 
from  pressure  on  sensory  nerves.  The  glands  are  not  tender 
and  are  freely  movable. 

The  disease  progresses  rapidly,  with  periods  of  improve- 
ment, and  regularly  lasts  a  number  of  years. 

Diagnosis :  The  disease  must  be  differentiated  from  leu- 
kaemia, which  is  done  by  the  blood-examination,  and  from 
tubercular  adenitis.  In  the  latter  condition  the  glands  are 
prone  to  fuse  together,  soften,  and  suppurate,  all  of  which 
phenomena  are  rare  in  pseudoleukemia.  In  the  splenic 
form  splenic  leukaemia  is  distinguished  by  the  blood-exami- 
nation ;  and  other  causes  of  splenic  enlargement  must  be 
excluded  before  diagnosing  splenic  pseudoleukemia. 

Prognosis :  Absolute  recovery  is  rare,  but  temporary  im- 
provements extending  over  many  years  are  often  seen.  Where 
the  deeper  glands  are  involved  the  cases  seem  more  serious. 

Pseudoleuksemia — treatment :  The  patient  must  be  kept 
under  strict  hygienic  surroundings,  with  good  food,  good  air, 
and  moderate  exercise.  Of  drugs,  arsenic  seems  the  only  one 
of  much  value ;  it  is  given  in  gradually  increasing  closes. 
The  iodides  at  times  seem  useful. 

The  question  of  the  operative  removal  of  the  enlarged 
glands  has  much  to  be  said  on  both  sides.  At  times,  after 
operation,  there  seems  to  be  a  fresh  outburst  of  the  disease 
elsewhere.  At  other  times  good  results  follow.  Operation 
is  indicated  when  pressure-symptoms  are  causing  trouble. 

ADDISON'S  DISEASE. 

Definition :  This  is  a  disease  characterized  by  anaemia, 
general  languor  and  debility,  feeble  heart-action,  irritability 
of  the  stomach,  bronzing  of  the  skin,  and  disease  of  the 
suprarenal  capsules. 

Etiology :  It  is  a  rare  disease  under  any  circumstances,  but 
especially  so  in  children.     A  few  cases  are  recorded  under 


HAEMOPHILIA.  205 

fifteen  years  of  age,  some  being  in  mere  babies.  The  causal 
conditions  are  not  known. 

Pathology  :  The  supra-renal  capsules  are  usually  the  seat  of 
a  tubercular  inflammation,  with  conversion  of  the  glands  into 
cheesy  and  fibrous  tissue.  At  other  times  they  are  atrophied 
or  absent.  There  is  a  deposit  of  pigment  in  the  cutis  vera. 
The  blood  shows  a  decrease  in  red  cells  and  haemoglobin,  but 
no  change  in  the  white  cells. 

Addison's  disease — symptoms  :  There  is  a  slow,  gradual  loss 
of  flesh  and  strength.  The  mind  becomes  dull  and  apathetic. 
The  temper  is  often  highly  irritable.  The  action  of  the  heart 
grows  very  rapid  and  feeble.  Dyspnoea  is  present,  increased 
by  exertion.  The  stomach  is  upset ;  there  are  pains,  nausea, 
and  vomiting. 

The  typical  bronzing  of  the  skin  is  most  evident  on  the  face 
and  hands,  and  in  the  regions  where  the  skin  is  naturally 
most  pigmented. 

Patches  are  also  found  on  the  various  mucous  membranes, 
as  that  of  the  mouth. 

Toward  the  end  asthenia  becomes  most  marked,  and  stupor, 
delirium,  coma,  or  convulsions  may  occur.  The  disease  is 
chronic,  but  progressive  in  its  course,  and  with  its  periods  of 
remission  and  exacerbation  may  last  for  years. 

Diagnosis :  This  is  difficult  except  in  cases  where  all  the 
typical  symptoms  are  present  at  the  same  time. 

Prognosis  :  This  is  bad,  as  almost  all  the  cases  die  in  a  few 
years.     General  tuberculosis  may  develop. 

Addison's  disease — treatment :  Absolute  rest  and  nourishing 
and  digestible  diet  are  of  prime  importance.  Iron,  arsenic, 
strychnine,  and  phosphorus  are  all  recommended  as  useful 
drugs. 

HEMOPHILIA. 

Definition:  This  is  a  condition  in  which  even  after  the 
slightest  injury  hemorrhage,  which  is  very  difficult  to  control, 
occurs.     Such  a  person  is  called  a  "bleeder." 

Etiology:  There  is  a  marked  hereditary  tendency  to  the 
disease.      It  is  transmitted  through  the  female  xid<-  of  a  luemo- 


206         DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

philic  family,   but   regularly  appears  in   the  male  members. 
No  real  cause  for  the  disease  is  known. 

Pathology :  No  marked  changes  either  in  the  blood  or  in 
the  bloodvessels  are  found.  In  a  few  cases  the  walls  of  the 
vessels  seem  to  be  very  thin.  In  the  other  tissues  nothing 
abnormal  is  found. 

Haemophilia — symptoms :  As  a  rule,  there  is  nothing  in  the 
appearance  of  the  child  to  suggest  that  he  is  a  "  bleeder." 
The  first  sign  is  apt  to  be  a  prolonged  hemorrhage  from  some 
trifling  wound,  or  from  some  mucous  membrane.  Epistaxis 
is  the  commonest  form  of  bleeding.  The  bleedings  usually 
do  not  make  their  appearance  before  the  second  year.  For 
instance,  such  hemorrhages  from  the  umbilical  cord  are  rare. 
The  first  hemorrhage  is  apt  to  be  recovered  from.  The  fatal 
ones,  as  a  rule,  are  subsequent.  Petechia?  in  the  skin,  or 
hematoma  in  the  deeper  parts,  are  apt  to  take  place.  In 
some  cases  there  are  swelling  and  inflammatory  signs  in  the 
joints. 

Diagnosis :  No  way  exists  to  tell  that  these  children  are 
"  bleeders,"  except  by  experience  with  a  wound  in  each  indi- 
vidual case. 

Prognosis :  A  large  proportion  of  these  cases  never  reach 
adult  life.  They  are  in  constant  danger  of  death  from  hem- 
orrhage from  a  small  or  large  traumatism. 

In  the  few  women  who  are  "  bleeders,"  neither  in  menstrua- 
tion nor  in  parturition  does  the  haemophilia  seem  to  add  to 
the  dangers. 

Haemophilia — treatment :  In  case  of  bleeding  the  usual  sur- 
gical measures — pressure,  position,  plugging,  and  ligaturing — 
should  be  followed.  If  a  coagulum  is  formed,  great  care  should 
be  taken  not  to  disturb  it. 

After  the  bleeding  is  stopped  measures  should  be  taken  to 
prevent  further  accidents.  All  minor  operations  and  all  trau- 
matisms should  be  avoided,  vaccination  and  pulling  of  the 
teeth  being  among  these.  The  child  should  be  kept  in  the 
open  air  and  given  plenty  of  exercise  and  iron.  There  seems 
some  value  in  giving  lime  salts  over  a  considerable  length  of 
time.     Girls  in  these  families  should  not  marry. 


PURPURA.  207 


PURPURA. 


Definition  :  This  term  is  used  to  include  spontaneous  hemor- 
rhages into  the  skin,  mucous  membranes,  and  internal 
organs.  The  different  varieties  have  received  different  names  ; 
but  they  all  seem  related  except  in  degree,  and  hence  will  be 
grouped  together.  Such  varieties  are  purpura  simplex,  in 
which  purpuric  spots  are  seen  in  the  skin  ;  purpura  hemorrha- 
gica, or  Werlhof's  disease,  in  which  in  addition  free  hemor- 
rhages appear  from  one  or  another  of  the  mucous  membranes  ; 
and  rheumatic  purpura,  or  peliosis  rheumatica,  occurring  in 
cases  at  the  same  time  suffering  from  inflamed  joints. 

Etiology  :  This  is  quite  a  common  disease  of  children,  as  in 
them  the  bloodvessels  are  still  immature.  In  very  many 
cases  no  etiological  factor  can  be  made  out.  In  others,  such 
causes  as  cachexia  from  scurvy ;  tuberculosis ;  chronic  pul- 
monary or  intestinal  disorders ;  from  malignant  disease  or 
infections  from  septicaemia,  malignant  endocarditis ;  or  the 
exanthemata,  are  active.  Certain  drugs,  as  quinine,  the 
iodides,  chlorate  of  potassium,  and  phosphorus,  will  produce  it. 
A  few  cases  are  mechanical  from  venous  stasis,  as  in  endo- 
carditis, pertussis,  and  epilepsy.  In  others  the  rheumatic 
diathesis  seems  in  some  way  to  act  as  a  cause.  In  others 
there  is  reason  for  believing  that  some  form  of  micro-organism 
is  the  actual  cause.    This  is  especially  true  in  Werlhof's  disease. 

Pathology :  In  the  blood  itself  no  changes  have  as  yet  been 
demonstrated  other  than  those  of  slight  anaemia.  In  some 
cases  the  walls  of  the  small  arteries  and  capillaries,  from 
which  the  hemorrhages  regularly  take  place,  are  found  in  an 
abnormal  condition,  permitting  free  escape  of  the  blood  through 
them.  In  the  variety  with  an  infectious  origin  an  infectious 
embolus  followed  by  thrombosis  and  inflammation  of  the  wall 
of  the  vessel  is  found.  In  the  very  acute  hemorrhagic  cases 
different  forms  of  germs  have  been  found,  but  no  specific  one. 

Hemorrhagic  areas  are  found  in  the  skin,  the  serous  and 
mucous  membranes,  the  joints,  and  the  viscera.  The  spleen 
is  usually  enlarged. 

Purpura — symptoms  :  These  vary  a  good  deal  with  the  form 
of  purpura  present. 


208         DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

In  purpura  simplex  there  may  be  no  constitutional  symp- 
toms at  all,  or  slight  fever  with  its  accompanying  malaise, 
anorexia,  and  headache,  may  be  present.  The  local  symp- 
toms are  the  occurrence  of  hemorrhagic  spots  or  blotches  sit- 
uated in  almost  any  part  of  the  skin.  These  spots  are  a  dark 
red  at  first,  later  fading  to  a  brown,  and  then  to  a  yellow. 
They  are  not  tender  and  do  not  disappear  on  pressure.  After 
fading  some  pigmentation  is  left  for  a  considerable  time.  In 
the  course  of  two  or  three  weeks  the  disease  is  over. 

In  purpura  hemorrhagica  there  are  regularly  present  more 
or  less  marked  constitutional  symptoms,  as  fever,  headache, 
prostration,  and  digestive  disturbances.  With  these  occur 
extravasations  into  the  skin  and  free  bleedings  from  the  mu- 
cous membranes.  These  hemorrhages  are  from  the  nose, 
mouth,  throat,  stomach,  lungs,  intestines,  or  genito-urinary 
tract.  In  many  cases  the  bleeding  is  severe  enough  to  en- 
danger life.  In  other  cases  the  hemorrhage  may  take  place 
en  masse  in  some  internal  portion  of  the  body  where  the  tis- 
sues are  loose,  as  the  orbit,  producing  exophthalmos. 

Some  of  the  more  severe  cases  of  this  variety  run  a  very 
rapid  fatal  course,  presenting  the  symptoms  of  an  infectious 
disease  with  high  fever  and  signs  of  general  toxaemia.  All 
of  these  hemorrhagic  cases  last  several  weeks,  and,  if  recovery 
occurs,  the  patient  is  left  anaemic  and  feeble. 

In  purpura  rheumatica  the  symptoms  are  those  of  acute 
rheumatism  of  one  or  more  joints  with  the  lesions  of  simple 
purpura  added.  They  are  probably  not  cases  of  actual  rheu- 
matism, however.  The  joints  are  inflamed,  red,  hot,  swollen, 
and  tender.  There  are  fever,  with  its  accompaniments,  and 
on  the  extremities  purpuric  spots  scattered  irregularly  about. 
This  form  lasts  several  weeks  and  relapses  are  quite  common. 

Diagnosis  :  Purpura  being  more  of  a  symptom  than  a  dis- 
ease, diagnosis  in  any  variety  is  fairly  easy.  Scurvy  is  dif- 
ferentiated by  its  signs  in  the  gums,  the  different  locality  of 
the  hemorrhages,  the  etiology,  and,  if  necessary,  by  the  effects 
of  treatment.  Hemophilia  is  distinguished  by  the  family 
history  and  the  absence  of  constitutional  symptoms.  If  possi- 
ble, the  cause  of  the  purpura  must  be  diagnosed  as  well  as 
the  presence  of  the  disease. 


PURPURA.  209 

Prognosis :  The  large  proportion  of  cases  end  in  recovery. 
The  fatal  cases  are  the  very  severe  ones  of  the  hemorrhagic 
variety,  with  marked  symptoms  of  infection,  the  so-called 
purpura  fulminans.     Relapses  are  common. 

Purpura — treatment :  The  patient  should  be  put  to  bed  and 
on  a  nourishing  diet.  The  causal  factor  should  be  searched 
for  and  treated,  if  possible.  Tonics,  as  iron  and  arsenic,  are 
indicated.  Stimulants  should  be  used  in  the  presence  of 
fever  and  toxsemia.  Fresh  fruit-juice  and  vegetables  should 
be  tried  on  account  of  their  value  in  the  similar  condition  of 
scurvy. 

Of  drugs,  aromatic  sulphuric  acid,  turpentine,  ergot,  tannic 
or  gallic  acid  and  calcium  chloride  have  been  used.     In  the 
rheumatic  form  the  salicylates  should  be  given. 
14— D.  c. 


CHAPTER    IX. 

DISEASES  OF  THE  KESPIRATORY  SYSTEM. 

DISEASES  OF  THE  NOSE. 

EPISTAXIS. 

Hemorrhage  from  the  nose  is  quite  a  common  occurrence  in 
children. 

Etiology :  Boys  are  more  apt  to  surfer  from  nose-bleed  than 
girls.  It  occurs  especially  in  delicate  children  who  are  not 
accustomed  to  outdoor  life.  It  is  often  a  symptom  of  ade- 
noids and  of  rhinitis.  It  may  begin  without  any  exciting 
cause,  but  more  often  follows  picking  the  nose,  a  slight  blow 
on  the  nose,  or  other  local  injury.  Severe  exertion  may 
bring  on  an  attack.  It  occurs  in  cases  of  endocarditis  and 
other  conditions  in  which  there  is  venous  stasis  of  the  blood. 
It  may  be  an  early  symptom  of  typhoid  fever,  malaria,  or 
almost  any  of  the  infectious  diseases.  It  may  be  part  of  the 
hemophilic  diathesis  or  a  complication  of  almost  any  of  the 
anaemias. 

Pathology :  The  source  of  the  blood  may  be  situated  almost 
anywhere  in  the  nasal  fossae,  but  usually  is  in  the  anterior 
nares.  Asa  rule  there  is  a  small  erosion  of  the  mucous  mem- 
brane, which  may  be  situated  over  a  fair-sized  vessel,  in 
which  case  the  bleeding  is  more  marked  than  when  there  is 
capillary  oozing  only. 

Epistaxis — symptoms  :  Bleeding  from  the  nose  is  the  only 
sign  of  any  moment.  The  blood  may  come  from  one  or  both 
nostrils,  or,  if  the  bleeding  point  is  posterior,  it  frequently 
will  come  through  the  pharynx,  the  blood  being  either  spit 
up  or  swallowed.  In  some  cases  the  bleedings  maybe  large 
enough  to  produce  feelings  of  faintness  and  to  leave  the  child 

210 


ACUTE  RHINITIS.  211 

anaemic.     The  hemorrhages  as  a  rule  last  only  a  few  minutes, 
but  recurrences  are  common. 

Diagnosis  :  It  is,  of  course,  easy  to  make  the  diagnosis  of 
epistaxis,  but  it  is  at  the  same  time  important  to  find  the 
cause  of  the  bleeding  and  its  exact  source. 

Prognosis  :  Ordinarily  epistaxis  is  a  simple,  harmless  trou- 
ble. In  the  various  constitutional  diatheses  of  which  it  is  a 
symptom,  as  hemophilia  and  the  anaemias,  it  is  more  serious. 
In  conditions  of  venous  stasis  from  any  cause  it  is  ordinarily 
helpful.  Occurring  in  the  late  stages  of  the  infectious  dis- 
eases it  indicates  a  serious  form  of  the  disease. 

Epistaxis — treatment :  A  child  prone  to  attacks  of  epistaxis 
should  be  put  under  the  best  hygienic  conditions,  and  by 
the  use  of  daily  cold  baths  and  being  kept  in  the  fresh  air 
should  have  his  mucous  membranes  toughened  so  as  to  resist 
changes  in  temperature.  If  the  epistaxis  is  due  to  any  of  the 
predisposing  causes,  as  rhinitis,  adenoids,  venous  congestion, 
or  any  of  the  hemorrhagic  diatheses,  these  should  be  treated. 

In  an  attack  the  local  application  of  cold  to  the  nose 
externally,  or  to  the  back  of  the  neck,  or  in  the  nostril,  will 
usually  stop  the  bleeding.  If  these  are  not  effective,  astrin- 
gent solutions  may  be  applied  to  the  nostrils,  such  as  tannic 
acid,  anti pyrin,  or  alum.  In  other  cases  the  anterior  nares 
may  be  plugged  with  cotton.  In  more  severe  cases  the  pos- 
terior nares  had  better  be  plugged  at  the  same  time.  This 
may  easily  be  done  by  passing  a  soft-rubber  catheter,  in 
which  a  piece  of  silk  is  threaded,  through  the  nostril  into  the 
pharynx.  The  catheter  is  withdrawn,  the  silk  being  left  in 
place  by  catching  the  end  with  a  pair  of  forceps.  With  this 
silk  a  piece  of  cotton  can  be  drawn  into  the  naso-pharynx  and 
tied  there. 

After  the  hemorrhage  has  ceased  it  is  wise  to  examine  the 
nares  carefully  for  the  bleeding  spot,  and  to  touch  this  with 
silver  nitrate. 

ACUTE  RHINITIS. 

This  is  commonly  called  ''  cold  in  the  head,"  and  technically 
coryza. 

Etiology:  This  very  common  disease  of  adull  life  is  equally 


212  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

often  seen  in  babies  and  children.  It  is  seen  oftenest  in  chil- 
dren who  are  coddled  too  much,  being  dressed  too  warmly, 
and  kept  in  overheated,  un ventilated  rooms,  and  never 
bathed  in  cool  water. 

It  follows  exposure  to  draughts,  sudden  chilling  of  the  sur- 
face while  warm,  wet  feet,  and  cold  to  the  abdomen.  Prob- 
ably some  form  of  micro-organism  is  also  present  as  a  co- 
existing cause.  The  disease  certainly  seems  somewhat  infec- 
tious.    Coryza  is  an  early  symptom  of  measles. 

Pathology :  The  nasal  mucous  membrane  is  congested  and 
swollen,  and  at  first  has  a  very  scanty  secretion,  or  at  best 
only  a  watery  one.  Later,  as  the  inflammation  passes  off,  the 
mucous  glands  begin  to  secrete,  and  mucus  and  muco-pus  are 
discharged  in  large  quantities. 

Acute  rhinitis — symptoms :  The  nose  is  stuffed  up,  necessi- 
tating mouth-breathing,  and  in  infants  causing  difficulty  in 
nursing.  There  is  a  feeling  of  fulness  in  the  nose  and  frontal 
sinuses,  and  there  may  be  decided  aching  in  the  same  localities. 
There  are  slight  fever  and  general  malaise.  Sneezing  begins 
early.  At  first  there  is  no  discharge ;  later  there  is  a  profuse 
acrid  watery  one,  and  later  yet  mucus  and  muco-pus  in  large 
amounts  may  be  expelled  by  blowing.  If  the  naso-pharynx 
is  involved,  the  openings  of  the  Eustachian  tubes  may  be 
swollen,  and  ringing  in  the  ears  and  deafness  follow. 

The  attack  lasts  a  little  less  than  a  week,  but  the  mucous 
discharge  continues  for  some  time  longer.  Complications,  as 
excoriation  of  the  upper  lip,  ear-ache  from  catarrhal  otitis 
media,  conjunctivitis  from  extension  through  the  lachrymal 
duct,  and  cervical  adenitis  from  absorption  into  the  lymph- 
glands  may  be  present. 

Diagnosis  :  The  diagnosis  of  the  rhinitis  is  easy  enough  ;  but 
we  must  exclude  the  beginnings  of  measles,  influeuza,  or 
diphtheria,  and  the  presence  of  congenital  syphilis. 

Prognosis :  This  is  good.  Recovery  regularly  follows  in 
about  one  week.     Recurrences  are  frequent. 

Acute  rhinitis— treatment :  To  cure  the  tendency  to  catch- 
ing cold,  the  children  should  be  accustomed  to  sleeping  in 
cool,  well-ventilated  rooms,  and  to  being  out  of  doors  almost 
every  day.     They  should  be  warmly  and  properly  dressed, 


CHRONIC  RHINITIS.  213 

but  not  bundled  up.  Every  day  they  should  take  a  cool- 
water  sponge  or  plunge  after  the  cleansing  bath.  This  tones 
up  the  vascular  system,  and  keeps  it  more  resistant  to  sudden 
temperature-changes.  The  nose  and  naso-pharynx  should  be 
examined  for  any  chronic  conditions,  such  as  chronic  rhinitis 
or  adenoids,  that  may  be  present. 

To  treat  the  coryza  itself,  the  child  should  be  kept  indoors 
and  in  a  uniform  temperature.  A  purge  should  be  given 
early,  which  will  remove  the  congestion  and  hasten  the  in- 
flammatory process  in  the  nose.  After  this  there  may  be 
given  internally  some  combination  of  quinine,  belladonna, 
and  camphor,  as  in  "pill  rhinitis;"  or  of  quinine,  ammonium 
chloride,  camphor,  belladonna,  opium,  and  aconite,  as  in 
"  pill  coryza,"  in  small  doses  suitable  for  the  age  of  the  child, 
and  frequently  repeated.  The  nostrils  may  be  washed  out 
two  or  three  times  a  day  by  a  cleansing  solution,  such  as 
Seller'*',  and  then  a  little  melted  vaseline  poured  into  them. 
If  reduction  of  the  congestion  is  necessary,  a  weak  cocaine 
solution  may  be  used  cautiously.  A  blunt-pointed  piston 
syringe,  or  a  medicine-dropper,  or  aJBermingham  douche,  are 
better  for  these  local  applications  than  sprays  or  atomizers. 

CHRONIC    RHINITIS. 

This  is  a  chronic  inflammation  of  the  nasal  mucous  mem- 
brane in  which  there  is  neither  hypertrophy  nor  atrophy. 

Etiology:  Frequent  attacks  of  the  acute  form  are  the  com- 
monest cause.  Adnoids  in  the  naso-pharynx,  foreign  bodies 
in  the  nose,  and  nasal  polyps  are  often  found  in  these  cases. 

Chronic  rhinitis — symptoms:  A  mucous  or  muco-purulent 
discharge  from  the  nostrils,  of  greater  or  less  amount,  is  the 
early  symptom  of  this  disease.  The  edges  of  the  nostrils  and 
the  upper  lip  may  be  excoriated  by  the  discharge.  The  dis- 
charge can  usually  be  easily  removed  by  blowing. 

Diagnosis :  A  thorough  examination  of  the  anterior  and 
posterior  nares  should  be  made  when  possible,  to  discover  the 
condition  of  the  nasal  mucous  membrane  and  the  presence  of 
any  of  the  local  causes. 

Prognosis:  The  disease  may  be  cured  by  proper  treatment; 


214         DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

but  if  left  alone,  it  is  apt  to  terminate  in  one  of  the  more 
serious  forms  of  chronic  rhinitis,  the  hypertrophic,  or  more 
often  the  atrophic. 

Chronic  rhinitis — treatment :  The  prophylactic  treatment 
recommended  for  acute  rhinitis  must  be  followed.  Local 
causes,  if  they  exist,  must  be  removed,  such  as  adenoids, 
polypi,  or  foreign  bodies.  The  nostrils  should  be  thoroughly 
cleaned  out  once  or  twice  a  day  by  spraying  or  syringing  with 
some  mild  alkaline  solution,  such  as  Seller's.  A  good  home 
wash  is  a  teaspoonful  each  of  soda,  salt,  and  borax  to  a  quart 
of  water.  Always  use  nasal  solutions  warm.  A  useful  and 
simple  little  instrument  for  this  purpose  is  the  Bermingham 
douche.  After  cleaning,  some  astringent  such  as  sulpho- 
carbolate  of  zinc  in  1  per  cent,  solution,  or  nitrate  of  silver 
in  1  or  2  per  cent,  solution,  should  be  applied  with  cotton. 

HYPERTROPHIC    RHINITIS. 

Definition  :  This  is  a  form  of  chronic  rhinitis  in  which  the 
nasal  mucous  membrane  is  very  much  hypertrophied,  block- 
ing up  the  nasal  fossa?  and  interfering  with  the  passage  of  air 
through  them. 

Etiology :  It  is  most  commonly  secondary  to  repeated  at- 
tacks of  acute  rhinitis. 

Pathology:  All  the  parts  of  the  mucous  membrane  are 
hyperplastic.  The  vascular  portion  is  particularly  affected, 
the  number  of  vessels  being  increased  and  their  size  enlarged. 
The  membrane  over  the  turbinated  bones  takes  on  the  char- 
acteristics of  erectile  tissue. 

Hypertrophic  rhinitis — symptoms  :  The  two  symptoms  com- 
monly present  are  nasal  discharge  and  obstructed  nasal 
breathing.  The  discharge  is  more  difficult  of  expulsion  than 
that  due  to  simple  rhinitis,  but  is  not  so  irritating  to  the 
upper  lip.  The  nasal  obstruction  leads  to  mouth-breathing 
and  to  the  so-called  nasal  tone  of  voice.  This  is  not  due  to 
talking  "  through  the  nose,"  but  to  the  inability  to  ventilate 
the  naso-pharynx  through  the  nose. 

Diagnosis  :  This  is  made  by  examining  the  anterior  and 
posterior  nares  when  possible.    The  turbinated  bodies  are  seen 


ATROPHIC  RHINITIS.  215 

to  be  swollen,  and  red  both  in  front  and  behind,  and  the  space 
of  the  nostrils  blocked  by  them  so  much  that  a  probe  is  passed 
with  difficulty. 

Prognosis :  Much  good  can  be  accomplished  by  removing 
this  hypertrophic  condition  by  treatment.  It  is  questionable 
if  the  inflammation  can  be  completely  cured.  If  untreated, 
the  cases  usually  go  on  to  atrophy. 

Hypertrophic  rhinitis — treatment :  The  same  prophylactic 
and  cleansing  measures  should  be  used  as  in  simple  chronic 
rhinitis.  The  hypertrophied  turbinates  can  be  reduced  by 
forming  a  linear  horizontal  scar  along  them  by  the  applica- 
tion of  nitric,  glacial  acetic,  or  chromic  acid,  or  by  the  use  of 
an  electro-cautery.  In  some  cases  the  mucous  membrane  is 
so  hypertrophied  that  portions  of  it  may  be  removed  by  a 
snare. 

ATROPHIC  RHINITIS. 

Atrophic  rhinitis  is  a  somewhat  rare  condition  in  children. 
It  is  often  called  ozsena  or  foetid  rhinitis.  These  terms  are 
better  reserved  for  cases  with  necrosis  of  the  bones  of  the 
nose. 

Etiology  :  It  is  sometimes  secondary  to  repeated  attacks  of 
acute  rhinitis  and  to  hypertrophic  rhinitis.  Other  cases  come 
without  known  cause. 

Pathology :  There  is  a  gradual  atrophy  of  all  the  elements 
of  the  nasal  mucous  membrane.  The  submucous  tissue  with 
its  glands  and  vessels  disappears  in  time. 

Atrophic  rhinitis — symptoms:  The  liquid  discharge  from 
the  nostrils  is  small.  On  the  contrary  the  secretions  dry  in 
the  fossa?,  and  form  crusts  and  scales  which  adhere  more  or 
less  firmly  to  the  mucous  membrane.  The  nostrils  are  roomy 
and  the  passage  of  air  through  them  free.  If  the  crusts  are 
allowed  to  accumulate,  they  begin  to  decompose  and  give  a 
disagreeable  odor  to  the  air  passing  through  the  nostrils. 
From  tin's  arises  the  name  foetid  rhinitis.  This  foetor  depends 
almost  entirely  on  the  lack  of  proper  cleansing  of  the  nostrils. 
The  naso-pharynx  and  the  pharynx  are  usually  the  scat  of 
an  atrophic  inflammation  at  the  same  time. 

Diagnosis:  Careful  inspection  of  the  anterior  and  posterior 


216         DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

nares,  showing  the  free  nasal  cavities,  the  pale  appearance  of 
the  mucous  membrane,  and  the  presence  of  crusts,  usually 
settles  the  diagnosis. 

Prognosis :  Cure  is  impossible,  but  amelioration  of  the 
symptoms  can  easily  be  brought  about,  and  a  little  con- 
tinuous care  afterward  will  prevent  their  recurrence. 

Atrophic  rhinitis — treatment :  This  consists  in  cleanliness, 
and  a  stimulating  application  to  the  nose  to  keep  the  mucous 
glands  secreting  as  much  as  possible.  For  purposes  of  clean- 
liness a  nasal  douche  of  warm  water  containing  some  alkali, 
as  soda,  salt,  or  borax,  or  Seller's  solution,  may  be  used  daily. 
This  may  be  given  by  the  ordinary  fountain-syringe  to  which 
a  nasal  nozzle  is  attached,  or  by  the  Bermingham  douche. 
After  washing,  some  stimulating  oily  solution  should  be 
applied,  as  menthol  or  thymol,  about  ten  grains  to  the  ounce 
of  sweet  oil.  If  the  foetor  is  bad,  listen  ne  may  be  added  to 
the  alkaline  douche.  Any  crusts  that  cannot  be  washed  out 
should  be  removed  mechanically  with  a  cotton-wrapped  probe. 

MEMBRANOUS  RHINITIS. 

This  is  nothing  more  nor  less  than  diphtheria  of  the  nose, 
and  on  account  of  its  importance  as  a  source  of  infection  in 
others  it  should  be  so  considered. 

Etiology :  The  Klebs-Loffler  bacillus  is  the  cause  of  almost 
all  the  cases  of  this  disease. 

Pathology  :  The  nasal  mucous  membrane  is  highly  inflamed, 
and  its  surface  coated  with  a  layer  of  false  membrane.  If 
the  inflammation  extends  backward  into  the  naso-pharynx, 
the  cervical  lymph-glands  will  be  enlarged  and  tender. 

Membranous  rhinitis — symptoms  :  The  local  symptoms  in  the 
nose  are  the  main  ones,  as,  unless  the  inflammation  spreads 
to  the  naso-pharynx,  absorption  is  slight,  and  hence  consti- 
tutional symptoms  few. 

There  are  obstruction  of  the  nares,  and  serous,  or  mucous, 
or  bloody  discharge  from  the  nostrils,  and  usually  excoriation 
of  the  upper  lip.  On  examination  the  nostrils  are  choked 
up,  and  the  gray  or  dirty  white  membrane  is  easily  seen 
covering  the  whole  of  the   inside  of   the  nose.     It  can  be 


SYPHILITIC  RHINITIS.  217 

removed  only  with  difficulty,  and  leaves  a  bleeding  place 
behind.  The  membrane  may  remain  localized  or  may  spread 
to  the  pharynx  or  larynx.  In  case  it  does  not  spread  the 
membrane  will  come  away  piecemeal,  or  as  a  whole,  in  the 
course  of  a  couple  of  weeks,  and  recovery  will  rapidly 
follow. 

Diagnosis :  This  depends  on  the  presence  of  a  false  mem- 
brane in  the  nose,  and  should  be  accompanied  by  a  bacterio- 
logical report  as  to  the  presence  or  absence  of  the  Klebs- 
LSffler  bacillus. 

Prognosis:  As  long  as  the  disease  remains  localized  in  the 
nose,  the  prognosis  is  fairly  good.  If  it  spreads,  the  case 
takes  on  the  characters  of  a  general  diphtheria. 

Membranous  rhinitis — treatment:  The  patient  should  be 
isolated,  and  the  nose  washed  out  two  or  three  times  a  day 
with  a  warm  weak  solution  of  bichloride  of  mercury,  about 
1  :  50,000  or  1  :  30,000.  The  question  of  giving  antitoxin 
will  depend  on  the  same  rules  as  in  general  diphtheria. 
Constitutional  treatment  of  other  kinds  will  seldom  be  needed. 

SYPHILITIC  RHINITIS. 

This  is  seen  with  some  frequency  in  infants  the  victims  of 
inherited  syphilis. 

Etiology :  The  disease  is  the  result  of  a  syphilis  contracted 
in  intra-uterine  life,  and  manifesting  itself  during  the  first 
three  or  four  months  of  extra-uterine  life. 

Pathology :  The  lesions  are  those  of  a  catarrhal  rhinitis. 
In  places,  superficial  ulcers,  the  so-called  mucous  patches, 
form   in  the  nostrils. 

In  other  children  the  lesions  are  those  of  the  tertiary  stage 
of  the  disease,  when  gummata  form  and  break  down,  with 
destruction  of  mucous  membrane,  cartilage,  and  bone.  The 
septum  may  be  perforated,  the  various  bones  may  necrose, 
and  marked  deformities  of  the  nose  may  follow.  The ^  so- 
called  "  saddle-back  "  nose  is  the  most  typical,  where  the  bridge 
is  sunken  and  the  nose  becomes  very  broad.  These  tertiary 
lesions  are  seldom  confined  to  the  nose,  but  the  hard  and  soft 
palates  are  usually  affected   coincident!}-.      Alter   syphilitic 


218         DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

ulceration,  cicatricial  healing  regularly  takes  place,  with  con 
traction  of  the  scar-tissue  subsequently  and  increase  of  the 
deformity. 

Syphilitic  rhinitis — symptoms :  In  the  secondary  form  a 
coryza,  or  the  so-called  "  snuffles,"  is  the  only  symptom.  The 
discharge  from  the  nose  is  serous,  or  mucous,  or  bloody,  and 
excoriates  the  upper  lip. 

In  the  tertiary  form  the  physical  signs,  as  described  under 
pathology,  together  with  a  very  offensive  odor  and  some  dis- 
charge, are  the  symptoms. 

Diagnosis  :  The  secondary  form  is  differentiated  from  simple 
coryza  mainly  by  its  longer  course  and  greater  discharge. 
Other  evidences  of  congenital  syphilis  should  be  looked  for, 
and  will  usually  be  found.  The  family  history  will  help  at 
times. 

In  the  tertiary  variety  the  signs  are  more  characteristic, 
ulceration  and  scars  being  often  seen  side  by  side. 

Prognosis :  This  is  that  of  syphilis  in  general,  in  children. 

Syphilitic  rhinitis — treatment :  Constitutional  treatment  for 
syphilis  should  be  at  once  instituted.  Locally,  the  nose  should 
be  kept  clean  by  an  alkaline  wash,  and  afterward  an  appli- 
cation of  bichloride  of  mercury  in  weak  solution  or  insuffla- 
tions of  calomel  powder  should  be  made. 

NASAL  POLYPI. 

Nasal  polypi  occur  only  in  older  children,  and  are  compar- 
atively rare  even  in  them. 

Etiology  :  The  causes  are  unknown  ;  but  polyps  seem  to  be 
always  secondary  to,  or  at  least  associated  with,  chronic  in- 
flammatory conditions  in  the  nose. 

Pathology :  The  polyps  are  usually  composed  of  a  mixture 
of  mucous  and  fibrous  tissue,  one  or  the  other  predominating. 
They  are  covered  with  ciliated  epithelium.  They  are  regu- 
larly pedunculated,  and  of  a  round  form  and  pink  color. 
They  originate  usually  from  the  middle  meatus. 

Nasal  polypi — symptoms  :  These  are  due  mainly  to  the  ac- 
companying rhinitis,  and  are  discharge  and  interference 
with  the  passage  of  air  through  the  affected  nostril.     There 


HAY  FEVER.  219 

may  be  headache  and  sneezing,  and  frequent  attacks  of  acute 
coryza. 

Diagnosis :  This  depends  on  a  careful  examination  of  the 
nostrils  and  the  discovery  of  the  pale,  soft  pediculated  growth. 
Frequently  a  number  of  polypi  will  be  found  at  the  same 
time. 

Prognosis :  Polyps  are  not  serious,  but  are  troublesome ; 
and  unfortunately,  after  removal,  have  a  tendency  to  recur. 

Nasal  polypi — treatment :  The  polyps  are  best  removed  by 
the  cold-wire  snare  passed  nround  the  pedicle  and  drawn  tight. 
After  removal  the  base,  if  it  can  be  found,  should  be  cauter- 
ized. The  use  of  cocaine  makes  the  operation  easier.  The 
accompanying  chronic  rhinitis  should  be  carefully  treated  on 
the  regular  plan. 

HAY  FEVER. 

Synonyms :  This  is  also  called  rose  cold,  autumnal  catarrh, 
and  hay  asthma.  It  is  a  condition  of  intense  coryza,  with 
which  conjunctivitis  is  regularly,  and  asthma  often,  associated. 

Etiology  :  It  is  not  common  except  in  older  children.  The 
cause  is  not  known,  but  it  is  believed  to  be  a  neurotic  predis- 
position, and  the  presence  in  the  atmosphere  of  some  irritant 
arising  from  vegetation.  The  cases  regularly  begin  in  the 
fall  months,  and  usually  at  a  very  definite  time.  Certain 
localities  seem  perfectly  free  from  the  disease,  and  a  patient 
going  to  one  of  these  will  be  cured  almost  at  once. 

Pathology :  The  disease  is  functional ;  there  are  no  lesions, 
but  the  irritated  mucous  membranes  are  temporarily  in  a  state 
of  acute  inflammation  with  inci^eased  secretion. 

Hay  fever — symptoms  :  The  disease  begins  suddenly,  at  a 
rather  definite  time  of  year,  with  sneezing,  obstructed  nasal 
breathing,  a  watery  irritating  discharge  from  the  nostrils, 
lachrymation,  and  injected  conjunctivas.  The  nose  itches  ex- 
cessively and  the  sense  of  smell  is  much  impaired.  These 
symptoms  continue  throughout  the  attack'. 

In  certain  eases,  in  addition  to  the  involvement  of  the  nasal 
and  ocular  mucous  membranes,  the  bronchial  walls  and  lining 
are  invaded  and  the  patient  suffers  from  attacks  of  coughing, 
with  scanty  expectoration,  and  from  attacks  of  asthma.     The 


220         DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

difficult  breathing  is  continuous  day  and  night,  but  is  often 
exacerbated  and  may  become  very  distressing.  The  attacks 
last  for  a  month  or  six  weeks,  and  usually  disappear  with  the 
first  frost. 

Diagnosis  :  The  first  attack  may  be  a  little  difficult  to  recog- 
nize ;  but,  as  a  rule,  even  in  this  the  character  of  the  disease 
is  shown.     Subsequent  attacks  should  be  quickly  diagnosed. 

Prognosis :  It  is  not  a  serious  disease  ;  but  it  is  difficult  to 
cure  an  attack,  and  equally  so  to  prevent  subsequent  ones. 
Many  cases  of  undoubted  cures  are,  however,  reported. 

Hay  fever — treatment :  During  the  attack  much  relief  may 
be  afforded  by  applications  to  the  nose  of  atropine  in  1  per 
cent,  solution,  or  of  cocaine  in  2  per  cent,  solution.  Some 
ointment,  or  even  vaseline,  applied  to  the  nostrils  prevents 
excoriations  from  the  discharges. 

In  cases  with  asthma  combinations  of  belladonna  and 
iodide  of  potassium  given  internally  produce  relief.  The 
inhalation  of  smoke  from  stramonium  cigarettes  is  often 
helpful. 

Between  attacks  the  nostrils  and  naso-pharynx  should  be 
carefully  searched  for  any  abnormalities,  and  these,  if  found, 
should  be  thoroughly  treated. 

If  no  amelioration  can  be  effected,  the  child  should  be  sent 
away  regularly  to  a  region  free  from  the  disease  during  the 
time  of  its  prevalence. 

DISEASES   OF   THE   LARYNX. 

SPASMODIC  LARYNGITIS. 

This  disease  is  also  called  laryngismus  stridulus  and  spas- 
modic croup. 

Etiology  :  This  disease  is  a  neurosis  of  the  internal  laryngeal 
muscles.  It  is  seen  most  often  in  rachitic  children  or  in 
those  suffering  from  any  form  of  malnutrition.  In  these 
conditions  all  the  reflexes  are  markedly  increased.  Children 
of  a  neurotic  heredity  are  often  affected.  Local  causes  are 
frequently  found,  such  as  adenoids,  hypertrophied  tonsils, 
elongated  uvula,  or  acute  inflammations  of  the  throat,  nose, 


SPASMODIC  LARYNGITIS.  221 

or  bronchi.  Indigestion,  exposure  to  draughts,  excessive 
exertion,  and  great  emotion  will  often  excite  attacks. 

Pathology  :  There  are  no  lesions  of  this  disease.  The  con- 
dition is  a  reflex  spasm  of  the  laryngeal  muscles.  The  patho- 
logical changes  of  the  predisposing  diseases  are  found. 

Spasmodic"  laryngitis — symptoms  :  The  symptoms  consist  in 
sudden,  unexpected  attacks  of  interference  with  the  passage 
of  air  through  the  larynx.  The  spasm  seems  at  first  to  close 
the  glottis  completely,  and  during  this  time  the  child  changes 
from  a  pale  to  a  cyanotic  color,  throws  back  his  head,  and 
makes  violent  efforts  to  breathe.  In  about  half  a  minute  the 
spasm  gradually  relaxes,  and  this  is  shown  by  a  noisy  crowing 
or  stridulous  inspiration.  Expiration  is,  however,  more  diffi- 
cult. This  may  be  the  end,  but  recurrences  in  a  few  minutes 
or  hours  are  to  be  expected.  There  may  be  a  great  many 
paroxysms  during  the  day. 

General  convulsions  and  tetany  are  apt  to  complicate  the 
attacks.  There  are  all  grades  of  severity  to  the  paroxysm, 
from  the  mildest  form  which  may  be  scarcely  noticeable  to  a 
spasm  so  severe  and  prolonged  as  to  endanger  life.  The 
tendency  to  recurring  attacks  lasts  usually  from  a  few  weeks 
to  a  month  or  two. 

Diagnosis :  The  disease  must  be  differentiated  from  ca- 
tarrhal laryngitis  and  from  diphtheria  of  the  larynx.  The 
suddenness  of  the  seizure  and  the  intermissions  in  the  attacks, 
together  with  the  absence  of  fever  and  other  signs  of  inflam- 
matory stenosis  of  the  larynx,  suffice  for  a  diagnosis.  The 
general  condition  of  the  child  also  assists. 

With  a  little  care  in  following;  the  historv  there  should  be 
no  occasion  to  confuse  the  disease  with  whooping-cough. 

Prognosis  :  The  prognosis  is  good,  although  fatal  cases  do 
occur.  The  presence  of  general  convulsions,  the  general 
condition  of  the  child,  and  the  severity  of  the  paroxysm  must 
be  taken  into  consideration  in  estimating  the  chances  for 
recovery. 

Spasmodic  laryngitis — treatment:  To  relieve  the  spasm, 
strong  counter-irritation  to  the  skin  is  quickly  efficacious. 
This  may  be  brought  about  by  dashing  cold  water  on  the 
head   and    lace  or  by  putting   the   patient  in   a  hof  bath.       In 


222  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

more  severe  cases  chloroform-inhalations  may  be  used,  and 
at  times  intubation  may  be  necessary. 

In  the  intervals  between  attacks  antispasmodics  should  be 
given  to  prevent  recurrences.  The  best  drugs  of  this  class 
are  bromide  of  potassium,  chloral,  and  antipyrin.  They  may 
be  used  separately  or  in  combination,  and  should  be  given  so 
as  to  keep  up  a  continuous  impression  on  the  nervous  system. 

To  remove  the  tendency  to  attacks,  all  measures  directed 
to  improving  the  child's  general  health,  particularly  its 
nutrition  and  digestion,  should  be  carefully  followed  out. 
Fresh  air,  cool  bathing,  and  proper  food  should  be  insisted 
on.  Rickets  must  be  treated,  if  present.  The  nose,  naso- 
pharynx, and  throat  should  be  carefully  examined,  and  any 
abnormalities  that  are  found  should  be  properly  treated. 


ACUTE  CATARRHAL  LARYNGITIS. 

This  disease  is  also  called  catarrhal  croup,  and,  in  its  milder 
or  severer  form,  is  the  ordinary  croup  from  which  children 
so  frequently  suffer. 

Etiology :  The  disease  commonly  results  from  exposure  to 
cold,  or  damp,  or  draught,  in  a  child  that  is  ordinarily  too 
much  protected  from  these  influences.  It  occurs  most  com- 
monly before  the  third  year,  but  is  seen  even  in  much  older 
children.  Certain  children  have  a  marked  predisposition  to 
the  disease,  attacks  recurring  with  great  persistency.  It  often 
complicates  influenza,  measles,  scarlet  fever,  or  others  of  the 
infectious  diseases. 

Pathology :  The  mucous  membrane  of  the  larynx  is  hyper- 
semic  and  swollen,  with — in  the  beginning — a  diminished  se- 
cretion, so  that  the  membrane  is  dry.  As  the  disease  ad- 
vances the  secretion  increases  until  it  eventually  becomes 
abnormally  large  in  q  uantity .  The  swollen  mucous  membrane 
over  the  cords  decreases  the  space  of  the  glottis,  and,  as  more 
or  less  muscular  spasm  usually  accompanies  the  inflamma- 
tion, the  stenosis  becomes  more  marked.  In  the  severe  and 
prolonged  form,  the  trachea  takes  part  in  the  inflammatory 
process. 

Acute  catarrhal  laryngitis — symptoms :   In  the  milder  cases, 


ACUTE  CATARRHAL   LARYNGITIS.  223 

which  are  the  ones  ordinarily  seen,  about  the  only  symptoms 
are  a  change  in  the  character  of  the  voice.  This  becomes 
hoarse  and  at  times  metallic.  In  young  infants  it  can  only 
be  noticed  when  crying,  but  in  older  children  the  spoken 
voice  also  shows  it.  At  times  aphonia  may  be  present:.  A 
cough  of  a  dry,  brassy  character  usually  accompanies  this. 
If  the  chink  of  the  glottis  is  much  narrowed,  particularly  if 
some  adductor  spasm  is  present,  as  so  often  is  seen  in  these 
cases,  there  is  more  or  less  interference  with  the  breathing, 
which  is  the  alarming  symptom  of  the-disease. 

The  constitutional  symptoms  are  slight,  the  temperature 
rising  only  a  degree  or  two,  and  the  child  not  feeling  at  all 
sick.  These  cases  regularly  have  an  exacerbation  of  the 
symptoms  during  the  night,  with  remissions  during  the  day. 

In  the  severe  cases  the  symptoms  due  to  the  larynx  are  the 
same,  but  intensified  ;  a  croupy  voice  and  cough,  no  expectora- 
tion at  first,  and  marked  interference  with  respiration.  The 
inspirations  are  stridulous  and  the  child  seems  to  be  suffo- 
cating. The  skin  becomes  somewhat  cyanotic  and  dyspnoea 
is  very  marked.  The  suprasternal  and  infracostal  spaces 
sink  somewhat  in  inspiration,  and  all  the  signs  of  laryngeal 
stenosis  are  present. 

The  constitutional  symptoms  are  likewise  marked.  The 
temperature  may  be  from  101°  to  104°  F.,  the  pulse  and  res- 
piration are  rapid,  and  the  child  seems  sick  and  prostrated. 
The  symptoms  increase  in  severity  for  two  or  three  days,  and 
then  gradually  diminish  as  the  mucous  glands  begin  to  secrete 
and  the  inflammation  to  be  resolved.  The  cases  usually  last 
about  a  week  or  ten  days,  unless  bronchial  or  pulmonary 
complications  set  in,  when  they  are  much  prolonged. 

Diagnosis  :  Spasmodic  laryngitis  is  distinguished  by  the  ab- 
sence of  fever  and  constitutional  symptoms,  by  its  occurring 
usually  in  rachitis,  and  by  its  paroxysmal  character. 

The  differentiation  from  membranous  laryngitis  is  more 
difficult  and  more  important.  The  dyspnoea  in  the  membra- 
nous form  is  more  constant,  and  does  not  show  the  daytime 
remissions  seen  in  catarrhal  croup.  The  presence  of  visible 
membranes  elsewhere  in  the  throat  is  almost  certain  proof  of 
the  membranous  variety.     Cultures  can  be  made  from    the 


224  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

pharynx  and  larynx  for  the  Klebs-Loffler  bacilli,  even  where 
no  membrane  can  be  seen.  In  doubtful  cases  where  other 
children  are  exposed  it  is  better  to  isolate  the  patient  until 
the  diagnosis  can  be  made  positive. 

Prognosis:  This  improves  with  the  age  of  the  child. 
Although  most  of  the  cases  recover,  still  caution  must  be 
used  in  prognosing,  as  very  severe  symptoms  may  develop, 
and  any  case  may  turn  out  to  be  of  the  membranous  variety. 

Acute  catarrhal  laryngitis — treatment :  The  child  should  be 
put  to  bed  in  a  room  with  a  uniform  temperature,  in  which 
the  air  is  artificially  moistened  by  steam,  and  put  on  a  lighter 
diet  than  it  normally  takes.  The  clothing  should  be  suffi- 
ciently warm,  and  the  neck  should  be  rubbed  with  campho- 
rated oil  or  turpentine,  and  then  bound  up  with  flannel.  A 
hot  mustard  foot-bath  may  also  be  given.  The  bowels  should 
be  opened  by  fractional  doses  of  calomel  given  hourly.  If 
the  case  is  in  any  way  severe,  the  child  should  be  under  a 
tent  and  breathe  steam  plain,  or  medicated  with  turpentine, 
creosote,  or  compound  tincture  of  benzoin.  Internally,  the 
so-called  expectorants  are  indicated,  of  which  the  best  are 
ipecac  and  antimony.  They  are  best  given  in  doses  just  short 
of  producing  emesis,  frequently  repeated  so  as  to  keep  up  a 
continuous  effect.  A  convenient  method  is  by  use  of  the  tab- 
let containing  t^~q  grain  each  of  ipecac  and  antimony,  or  com- 
binations of  the  wines  of  ipecac  and  antimony  with  ammo- 
nium chloride  may  be  used.  At  times  there  seems  value  in 
giving  repeated  doses  of  pilocarpine  until  the  laryngeal  mu- 
cous membrane  begins  to  secrete.  If  the  spasmodic  element 
is  marked,  chloral,  or  the  bromides,  or  antipyrin,  are  useful 
additions  and  are  indicated.  In  very  severe  cases  where 
medicinal  measures  do  not  relieve  the  stenosis,  recourse  must 
be  had  to  intubation. 

To  prevent  future  attacks  these  children  should  have  the 
nose  and  naso-pharynx  and  pharynx  carefully  examined  and 
any  abnormalities  found  treated.  Such  lesions  as  adenoids 
or  enlarged  tonsils  are  often  found,  and  act  as  predisposing 
causes.  Each  day  the  child  should  be  given  a  cool  bath,  and 
it  should  be  taken  out  of  doors  daily  and  accustomed  to  cool, 
fresh  air.     The  clothing  should  be  comfortably  warm,  but 


MEMBRANOUS  LARYNGITIS.  225 

not  too  heavy.     The  tendency  to  croup  can  be  completely 
removed  in  these  children  by  attention  to  these  little  details. 

MEMBRANOUS  LARYNGITIS. 

Synonyms  for  this  are  true  croup,  or  membranous  croup,  or 
laryngeal  diphtheria.  The  latter  particularly  must  be  re- 
membered, as  in  the  vast  majority  of  the  cases  the  whole 
disease  is  diphtheria  with  its  lesion  located  in  the  larynx. 

Etiology:  While  infection  by  the  Klebs-Lomer  bacillus  is, 
in  the  great  mass  of  the  cases,  the  cause  of  this  disease,  still 
pseudomembranes  may  rarely  form  in  the  larynx  from  irri- 
tation produced  by  the  streptococci,  and  at  times  after  intense 
chemical  irritants,  as  lye. 

Pathology :  There  is  an  inflammation  of  the  laryngeal 
mucous  membrane  so  intense  that  a  new  false  membrane  is 
formed  on  its  surface  and  attached  quite  intimately  to  it. 
The  false  membrane  by  its  mechanical  presence  blocks  up 
the  opening  between  the  cords,  which  is  already  diminished 
in  size  by  the  swelling.  In  this  false  membrane  the  Klebs- 
Loffier  bacillus  is  easily  demonstrated,  together  with  colonies 
of  streptococci. 

Membranous  laryngitis  —  symptoms:  The  constitutional 
symptoms,  particularly  early  in  the  disease,  are  quite  secon- 
dary to  the  local  symptoms  from  the  larynx.  The  disease 
begins  gradually  with  a  steadily  increasing  diminution  in  the 
calibre  of  the  glottis,  but  with  very  slight  or  no  remissions, 
thus  distinguishing  the  catarrhal  variety.  They  have  the 
croupy  voice  and  cough,  and  the  stridulous,  noisy  respiration. 
Later  on  aphonia  may  develop  and  the  stenosis  become 
marked  enough  to  produce  general  cyanosis  of  the  patient. 

In  the  meantime  the  fever  is  slight  and  the  pulse  only  a 
little  fast.  The  respiration  is  more  rapid.  As  the  dyspnoea 
increases  restlessness  and  excitement  and  a  struggle  for  air 
are  prominent  symptoms.  There  is  no  enlargement  of  the 
lymph-glands  in  the  neck.  All  these  signs  presuppose  the 
presence  of  pseudomembrane  only  in  the  larynx.  If  the 
resull  is  t<>  be  favorable,  after  four  or  five  days  the  cough 
grows   looser,  the  voice   returns,  the  breathing  is  easier,  and 

15— D.  C. 


226  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

often  fair-sized  pieces  of  false  membrane  are  spit  np.  If  the 
end  is  fatal,  all  the  dyspnceic  symptoms  increase  in  severity, 
and  cerebral  symptoms  become  especially  prominent,  as  rest- 
lessness, delirium,  and  convulsions  ;  or  stupor  and  coma. 
The  cases  are  rapid  in  their  course,  recovery  or  death  usually 
being  certain  by  the  end  of  a  week. 

The  spreading  of  the  membrane  to  the  lung,  setting  up 
bronchitis  or  pneumonia,  adds  an  important  element  to  the 
symptoms  of  the  disease. 

Diagnosis:  This  is  often  quite  difficult  to  make  in  the  be- 
ginning. The  presence  of  membrane  elsewhere  in  the  throat 
and  the  lack  of  general  symptoms  are  of  most  importance.  Bac- 
teriological examinations  should  be  made  in  any  doubtful  case. 

Prognosis  :  This  is  very  serious,  but  since  the  advent  of 
antitoxin  the  mortality  has  been  very  considerably  reduced. 

Membranous  laryngitis — treatment :  The  child  should  be 
put  to  bed  and  isolated  from  other  children  and  properly 
fed  and  stimulated.  In  preantitoxin  days,  emetics,  steam 
inhalations,  and  calomel  fumigations  were  used  as  the  medical 
treatment  of  this  disease.  At  the  present  time  they  may  be 
used  as  aids  to  the  specific  antitoxin  treatment,  but  are  never 
to  be  relied  on  alone.  Emetics  that  are  of  value  are  ipecac, 
or  antimony,  or  turpeth  mineral  given  in  small  doses  repeated 
frequently  until  vomiting  is  produced.  Plain  or  medicated 
steam  inhalations  are  used  in  the  same  way  as  in  catarrhal 
laryngitis,  under  a  tent.  Calomel  fumigations  are  given  by 
subliming  ten  to  twenty  grains  of  pure  calomel  over  an  alco- 
hol lamp,  the  calomel  being  placed  in  a  porcelain  receptacle. 
The  child  and  the  fumigating  apparatus  should  be  under  a 
tent,  and  the  only  caution  necessary  is  to  prevent  accidents 
by  fire.  Various  forms  of  apparatus  are  sold  for  this  pur- 
pose, but  by  a  little  ingenuity  a  simple  and  efficient  home- 
made one  may  be  devised.  The  fumigations  are  usually 
repeated  every  three  hours,  watching  results.  The  antitoxin 
should  be  given  early,  in  good-sized  dose,  and  repeated  in 
twelve  hours,  according  to  results.  In  cases  of  doubtful 
diagnosis  it  should  be  given  without  waiting  for  the  case  to 
develop  to  a  certainty,  as,  should  the  case  turn  out  to  be 
some  other  form,  no  harm  has  been  done. 


MEMBRANOUS  LARYNGITIS.  227 

Notwithstanding  antitoxin  and  medical  treatment,  very 
many  of  these  cases  require  mechanical  help  to  overcome  the 
laryngeal  stenosis,  and  it  is  due  to  these  only  in  many  cases 
that  the  child  is  saved  from  absolute  suffocation.  Mechani- 
cal measures  or  operative  procedures  are  indicated  by  a  stead- 
ily increasing  dyspnoea,  restlessness,  cyanosis,  and  retraction 
of  the  suprasternal  and  infracostal  regions.  It  is  always  a 
matter  of  some  anxiety  to  know  when  the  time  for  operation 
is  necessary,  and  there  is  no  good  rule  to  follow.  It  is,  how- 
ever, better  to  perform  it  too  early  than  too  late,  after  the 
child  is  exhausted  by  its  struggles  for  air  and  the  tissues  are 
poisoned,  by  the  venous  blood.  Of  the  two  operative  meas- 
ures employed,  intubation  and  tracheotomy,  the  evidence  in 
favor  of  the  former  is  steadily  increasing,  and  tracheotomy  is 
now  very  seldom  used  as  a  first  recourse,  but  only  in  certain 
cases  where  intubation  cannot  be  performed,  or  where  it  may 
have  failed.  Intubation  has  many  advantages  over  trache- 
otomy. It  is  simple,  it  is  more  easy  to  obtain  the  parents' 
consent  to  an  early  operation  ;  it  has  no  prejudicial  effects  on 
the  throat  in  forming  a  wound  for  fresh  infection  ;  if  it  fails, 
tracheotomy  can  be  done  as  easily  afterward  as  before,  and 
there  is  no  need  of  an  anaesthetic.  The  only  objections  are 
the  difficulty  in  feeding  some  children  who  are  wearing  tubes, 
and  the  rare  accident  of  crowding  false  membrane  into  the 
trachea  ahead  of  the  tube  and  spreading  the  infection,  and 
the  possibility  of  not  having  the  apparatus. 

Intubation  consists  in  the  passing  into  the  larynx  through 
the  mouth,  and  leaving  there,  a  tube  through  which  the  air 
passes  in  entering  and  leaving  the  lungs. 

The  O'Dwyer  apparatus  is  the  best  one  for  use.  It  consists 
of  various  sized  tubes,  an  introducer,  an  extractor,  a  mouth- 
gag,  a  gauge  for  deciding  the  size  of  the  tube  required,  and 
some  strong  silk. 

To  insert  the  tube  the  child  should  be  wrapped,  arms  and 
all,  in  a  blanket  or  .-heel,  and  then  held  upright  by  the  nurse 
with  his  head  resting  against  her  chest.  The  gag  is  inserted 
in  the  left  side  of  the  mouth.  The  operator  holds  the  tube 
on  the  introducer  in  his  right  hand,  the  silk  being  first  passed 
through  an  eye  in  the  tube  and  tin.'  ends  held   by  the  same 


228  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

hand.  He  then  passes  his  left  index  finger  over  the  epiglot- 
tis, and  thus  locates  the  upper  part  of  the  larynx.  With  this 
finger  as  a  guide  he  passes  the  end  of  the  tube  through  the 
space  between  the  cords  and  pushes  the  tube  easily  into  place. 
The  introducer  is  then  removed,  leaving  the  tube  with  its  at- 
tached silk  in  situ.  If  the  intubation  has  been  successful,  the 
relief  to  the  dyspnoea  is  immediate,  and  some  attempts  at 
coughing  are  usually  made.  If  unsuccessful,  the  tube  is 
again  affixed  to  the  introducer  and  again  introduced.  After 
the  child  quiets  down  from  the  intubation  and  becomes  accus- 
tomed to  the  tube,  the  silk  may  be  removed.  If  it  is  left,  it 
should  be  fastened  to  the  cheek  by  adhesive  plaster.  After 
a  successful  intubation  usually  very  few  troubles  arise.  One 
is  the  coughing  up  of  the  tube.  This  is  remedied  by  passing 
the  next  larger  size. 

Feeding  with  the  tube  in  place  should  usually  be  done  with 
the  head  held  lower  than  the  body,  or  at  least  lying  down ; 
and,  if  possible,  semi-solid  food  rather  than  liquids  should  be 
used.  If  the  tube  becomes  blocked,  it  is  usually  coughed  up 
by  the  patient ;  but  if  not,  it  must  be  quickly  extracted. 
During  the  wearing  of  a  tube  the  child  should  be  carefully 
watched  to  prevent  accidents,  and  the  physician  should  be 
within  easy  call  to  replace  a  coughed-up  tube  or  to  remove 
an  offending  one. 

In  removing  a  tube  the  child  is  held  in  the  same  way  as  in 
introduction.  With  the  left  index  finger  the  head  of  the  tube 
is  located,  and  on  this  as  a  guide  the  extractor  is  passed  into 
the  lumen  of  the  tube  and  the  tube  removed. 

The  time  for  removal  is  difficult  often  to  decide.  Await  the 
subsidence  of  the  disease  before  trying  it.  Often  after  re- 
moval it  will  have  to  be  reintroduced,  and  worn  for  a  few 
days  longer  before  it  can  be  safely  left  out. 

Tracheotomy  is  sometimes  necessary,  and  is  performed  in 
the  way  regularly  described  in  all  the  text-books  on  surgery. 

CHRONIC  LARYNGITIS. 

Chronic  inflammations  of  the  larynx  are  found  with  some 
frequency  in  infants  and  children. 


CHRONIC  LARYNGITIS.  229 

Etiology :  Most  of  the  cases  follow  attacks  of  acute  laryn- 
gitis, and  are  apt  to  be  associated  with  chronic  catarrhal  con- 
ditions elsewhere  in  the  throat.  Other  cases  are  due  to 
syphilis  and  others  to  tuberculosis. 

Pathology :  In  the  simple  catarrhal  cases  and  in  the  early 
syphilitic  ones,  the  mucous  membrane  is  in  a  state  of  chronic 
inflammation,  with  at  first  an  increased  and  later  a  decreased 
secretion,  and  hence  abnormal  dryness.  The  later  syphilitic 
form  attacks  the  deeper  tissues  of  the  larynx,  producing  ulcer- 
ation and  deformity. 

The  tubercular  cases  show  thickening  of  parts  of  the  larynx 
by  tubercular  infiltration,  and  later  necrosis  of  this  new  tis- 
sue with  ulceration. 

Chronic  laryngitis — symptoms  :  These  are  hoarseness,  a  dry 
cough,  more  or  less  aphonia,  and  a  thick,  sticky,  but  not  pro- 
fuse, expectoration.  In  the  tubercular  variety,  tubercle 
bacilli  may  be  found  in  the  sputum,  and  there  is  severe  pain 
on  swallowing. 

Diagnosis :  This  depends  on  the  above  symptoms,  in  addi- 
tion to  the  physical  signs  seen  on  examination.  Ulceration, 
with  involvement  of  the  arytenoid  areas,  usually  means  tuber- 
culosis. General  ulceration  with  scar-tissue  present  at  the 
same  time  usually  means  syphilis.  Evidence  of  either  dis- 
ease elsewhere  assists  the  diagnosis.  The  simple  variety  sim- 
ply shows  a  general  thickening  of  the  cords,  with  often  dried 
secretion  on  them. 

Prognosis  :  The  simple  form  can  usually  be  cured  by  re- 
moving the  cause.  The  tubercular  form  usually  complicates 
tuberculosis  elsewhere,  and  the  prognosis  is  that  of  tubercu- 
losis in  general. 

The  syphilitic  form  can  be  regularly  cured  ;  but  in  the 
tertiary  variety,  after  extensive  ulceration,  the  larynx  is  apt 
to  be  left  badly  deformed. 

Chronic  laryngitis — treatment:  In  the  simple  form,  atten- 
tion to  the  whole  pharynx  is  important.  Any  chronic  condi- 
tions there  must  be  treated.  The  larynx  should  he  touched 
daily  with  astringent  applications,  or  l>v  weak  solutions  of 
nitrate  of   silver,      inhalations  of   turpentine   or  of   tar   are 


230  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

valuable.  Internally,  expectorants  such  as  ammonia  and 
ipecac  may  be  given. 

In  the  syphilitic  variety,  the  main  reliance  is  to  be  placed 
on  antisyphilitic  treatment.  Local  applications  of  a  cleansing 
nature  often  aid.  With  marked  cicatricial  contraction  intu- 
bation is  often  necessary. 

In  the  tubercular  variety,  cleansing  applications  should  be 
made,  and  the  ulcers  touched  with  nitrate  of  silver,  or  lactic 
acid,  or  dusted  with  iodoform.  If  pain  on  swallowing  is 
marked,  applications  of  cocaine  give  temporary  relief.  Spe- 
cial means  should  be  taken  to  build  up  the  general  health,  and 
to  overnourish  the  child. 

PAPILLOMA  OF  THE  LARYNX. 

Papilloma  of  the  larynx  is  found  with  some  frequency  in 
children,  and  at  times  even  in  infancy.  Nothing  is  known 
as  to  its  causation. 

It  consists  of  one  or  more  warty  growths  from  the  neigh- 
borhood of  the  cords.  The  tumor  is  either  sessile  or  pedun- 
culated, and  presents  a  pinkish  appearance. 

Papilloma  of  the  larynx — symptoms:  The  symptoms  are 
hoarseness,  going  on  to  aphonia,  an  irritating  cough,  and  a 
gradually  increasing  dyspncea  as  the  growth  of  the  tumor 
blocks  up  the  larynx.  The  symptoms  progress  slowly,  as 
the  tumor  grows  slowly. 

Diagnosis  :  This  depends  on  direct  examination  with  the 
laryngoscope  if  possible.  If  not,  much  can  be  learned  by 
palpation  of  the  larynx  with  the  index  finger. 

Prognosis  :  This  is  not  good,  as  the  tumor  is  apt  to  recur 
after  removal,  and  seems  at  times  to  take  on  almost  a  malig- 
nant character. 

Papilloma  of  the  larynx — treatment :  In  some  older  children 
they  can  be  removed  by  endolaryngeal  operations  through 
the  mouth.  Most  cases  require  thyrotomy  and  the  excision 
of  the  growths.  In  some  cases  tracheotomy  and  leaving  the 
growth  entirely  alone  is  all  that  can  be  done. 


FOREIGN  BODY  IN  THE  LARYNX.  231 

(EDEMA  GLOTTIDIS. 

Definition  :  By  this  is  meant  an  effusion  of  serum  into  the 
submucous  tissue  of  the  larynx. 

Etiology  :  It  is  secondary  to  disease  elsewhere,  as  nephritis, 
and  occurs  often  as  a  complication  of  the  exanthemata.  It 
also  results  from  intense  local  irritation,  as  the  inhalation  of 
hot  vapors,  the  swallowing  of  corrosive  liquids,  and  from 
ulceration  and  foreign  bodies. 

Pathology :  The  cellular  submucous  tissue  is  infiltrated 
with  serum  and  with  new  cells.  The  larynx,  especially  in 
the  aryepiglottic  folds,  is  intensely  swollen. 

(Edema  glottidis — symptoms  :  The  characteristic  symptom 
is  inspiratory  dyspnoea,  expiration  being  comparatively  easy. 
If  any  local  inflammation  is  present,  there  is  intense  pain. 
The  symptoms  develop  rapidly,  and  in  a  few  hours  the  pa- 
tient may  be  in  danger  of  death  from  suffocation. 

Diagnosis :  A  laryngoscopic,  or  digital,  or  at  times  a  mere 
visual,  examination  will  settle  the  diagnosis. 

Prognosis  :  With  proper  treatment  this  is  good.  Untreated, 
the  mortality  is  high. 

(Edema  glottidis — treatment :  The  oedematous  tissues  must 
be  freely  scarified,  and  ice  must  be  given  to  swallow,  and  also 
packed  externally  around  the  throat.  In  some  cases  trache- 
otomy is  necessary.  Intubation  is  not,  as  a  rule,  very  suc- 
cessful. 

FOREIGN  BODY  IN  THE  LARYNX. 

This  occurs  from  time  to  time,  usually  as  a  result  of  a 
child  laughing,  <>r  crying,  or  coughing,  while  holding  some 
foreign  body  in  its  mouth.  It  may  lodge  in  the  larynx,  or 
trachea,  or  drop  down  into  a  bronchus,  usually  the  right  one. 

Symptoms:  Violent  paroxysmal  cough  and  dyspnoea,  with 
often  localized  pain  and  haemoptysis,  are  the  regular  results 
of  this  accident. 

Diagnosis:  This  depends  on  the  history  and  symptoms. 
In  a  few  cases  the  object  may  be  seen  by  the  laryngoscope. 

Prognosis:  In  many  cases  the  body  is  eventually  expelled. 
It  may  remain  and   be  encapsulated,  causing  no  trouble  ;  but 


232         DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

in  no  case  can  a  positive  prognosis,  good  or  bad,  be  given. 
There  is  always  danger  from  its  presence. 

Foreign  body  in  the  larynx — treatment :  The  patient  should 
be  inverted  and  shaken,  and  in  some  cases  the  body  will  be 
expelled.  If  impacted  in  the  larynx  or  trachea,  it  may  be 
removed  by  properly  constructed  forceps  either  through  the 
mouth  or  after  tracheotomy. 

DISEASES  OF  THE  BRONCHI,   LUNGS,  AND 
PLEURA. 

ACUTE  BRONCHITIS. 

Definition :  This  very  common  condition  in  infants  and 
children  is  an  inflammation  of  the  mucous  membrane  lining 
the  smaller  and  larger  bronchi. 

Etiology:  It  commonly  follows  exposure  to  cold  and  damp- 
ness. It  occurs  most  often  during  the  winter  months,  espe- 
cially when  the  changes  of  temperature  are  sudden  and 
marked.  Certain  children  seem  predisposed  to  the  disease, 
especially  those  who  have  frequent  attacks  of  coryza  and  sore 
throat.  It  is  often  secondary  to  the  infectious  diseases,  par- 
ticularly to  influenza,  measles,  and  whooping-cough.  It  is 
common  in  children  suffering  from  any  form  of  malnutrition, 
especially  rickets.  Micro-organisms  undoubtedly  play  a  prom- 
inent part  in  the  causation  of  this  disease. 

Pathology :  The  small  or  the  large,  or  both  kinds  of  tubes 
may  be  involved,  and  regularly  those  of  both  sides.  The 
mucous  membrane  is  congested  and  swollen,  the  superficial 
epithelium  is  shed,  and  the  glands  secrete  an  excessive  quan- 
tity of  mucus  and  muco-pus,  due  to  the  inflammatory  exudate. 

Acute  bronchitis — symptoms  :  The  disease  begins  gradually, 
and  frequently  after  a  preceding  coryza,  with  fever,  cough, 
and  malaise.  The  respiration  is  rapid,  and  the  child  is  rest- 
less and  fretful.  In  the  milder  cases  these  symptoms  last 
about  a  week  and  recovery  occurs. 

In  more  severe  eases  all  the  above  symptoms  are  intensified, 
the  temperature  runs  higher,  the  cough  becomes  distressing, 
and  the  respiration  quite  rapid  and  difficult,  but  its  normal 


ACUTE  BRONCHITIS.  233 

rhythm  is  retained.  The  pulse  is  rapid  and  the  child  de- 
cidedly prostrated.  In  the  early  stages  the  secretion  from 
the  bronchi  is  scanty  ;  and  later,  when  it  increases,  the  child 
swallows  what  it  coughs  up  into  the  throat.  Expectoration 
is  a  habit  formed  later  in  life,  the  young  child  always  swal- 
lowing its  sputa.  The  appetite  is  commonly  lost ;  there  may 
be  vomiting  and  diarrhoea.  In  these  severe  cases  the  disease 
lasts  for  a  couple  of  weeks,  and  may  be  protracted  even  over 
a  longer  time. 

Acute  bronchitis — physical  signs  :  In  the  very  beginning 
there  are  often  no  physical  signs,  save  the  very  rapid  respira- 
tion and  the  movement  of  the  ala?  nasi.  After  a  day  or  two 
both  chests  are  full  of  sibilant  and  sonorous  breathing. 
Later,  as  the  secretion  becomes  loose,  this  breathing  is  replaced 
by  very  numerous  fine  or  coarse  rales.  The  kind  of  rale  de- 
pends on  the  size  of  the  bronchi  in  which  it  is  formed.  As 
the  disease  advances  the  rales  grow  looser  and  fewer,  and 
gradually  disappear. 

Diagnosis  :  This  depends  on  the  history  and  the  physical 
signs.  The  only  difficulty  is  in  excluding  broncho-pneumo- 
nia, and  in  many  cases  this  may  be  impossible. 

Prognosis: — In  children  of  good  physique  this  is  good. 
Delicate  children,  those  the  subjects  of  rickets  or  of  the 
infectious  diseases,  and  very  young  infants  bear  the  disease 
badly.  In  young  infants  the  mucus  is  very  apt  to  block  up 
the  bronchi  and  to  impede  respiration  seriously. 

Acute  bronchitis — treatment :  The  child  should  be  kept  in 
the  house  in  an  equable  temperature,  and  put  on  a  light,  easily 
digestible  diet. 

It  should  be  given  first  fractional  doses  of  calomel  repeated 
till  the  bowels  move.  The  chest  should  be  rubbed  with  some 
mild  counterirritant,  as  camphorated  oil,  or  mustard  paste 
may  be  applied.  Internally  a  prescription  containing  small 
doses  of  an  expectorant,  such  as  ammonium  chloride  and 
ipecac,  may  be  given  and  repeated  frequently. 

Inhalations  of  steam,  containing  turpentine  or  creosote,  are 
often  useful.  Stimulants  are  frequently  necessary,  ami  brandy 
"i-  si  rychnine  may  be  used.  ( )pium  should  be  given  sparingly 
in  this  disease. 


234  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

In  cases  of  sudden  collapse,  or  of  respiratory  feebleness, 
nothing  acts  so  quickly  as  a  stimulant  as  a  hot  mustard  bath. 

CHRONIC  BRONCHITIS. 

Etiology :  This  condition  is  not  so  common  in  children  as 
in  adults.  It  regularly  follows  an  attack  of  acute  bronchitis 
in  a  patient  who  has  a  poor  constitution,  or  is  weak  from  some 
disease  which  the  acute  bronchitis  complicated. 

Pathology :  The  bronchial  mucous  membrane  is  in  a  con- 
dition of  chronic  catarrhal  inflammation,  with  an  excessive 
production  of  mucus. 

Chronic  bronchitis — symptoms :  A  troublesome,  persistent 
cough,  with  the  raising  of  a  great  deal  of  mucus,  are  the 
regular  symptoms  of  this  disease.  The  cough  is  apt  to  be 
worse  in  the  morning  and  at  night.  There  are  no  fever  and 
no  malaise,  and  very  little  interference  with  the  general 
health. 

Chronic  bronchitis — physical  signs  :  These  are  simply  the 
presence  of  coarse  mucous  rales  scattered  over  both  lungs. 

Diagnosis :  This  depends  on  the  cough  and  the  signs  in  the 
lungs.  Tuberculosis  must  be  excluded  by  the  difference  in 
the  physical  signs  and  the  absence  of  tubercle  bacilli  from  the 
sputum. 

Prognosis :  This  is  good,  as  most  of  these  children  by 
intelligent  treatment  can  be  cured. 

Chronic  bronchitis — treatment :  General  strengthening,  con- 
stitutional treatment  is  of  most  importance.  All  measures  to 
improve  the  child's  general  health  should  be  carefully  fol- 
lowed out.  These  children  should  not  be  confined  to  the 
house,  but  should  have  the  freedom  of  the  fresh  air  and  sun- 
shine in  good  weather.  A  change  of  climate  for  a  short  time 
will  often  be  very  beneficial.  As  drugs,  creosote,  tar,  or 
terebene  seem  of  most  value.  Iron  and  cod-liver  oil  are 
especially  helpful. 

FIBRINOUS  BRONCHITIS. 

Definition :  This  rather  rare  disease  consists  in  the  forma- 
tion  in   the   bronchi  of  false  membranes,  which   form   casts 


BRONCHO-PNEUMONIA.  235 

of  the  tubes  in  which  they  occur.  Some  cases  are  un- 
doubtedly diphtheritic,  but  others  are  not  so,  and  their  etiology 
is  unknown. 

Pathology :  The  trachea  and  large  bronchi  are  usually 
involved,  but  the  inflammation  may  reach  down  into  the 
bronchioles.  The  mucous  membrane  is  swollen  and  con- 
gested, and  coated  with  a  layer  of  coagulated  fibrin,  which 
may  be  free  in  the  lumen,  or  attached  to  the  surface  of  the 
bronchi. 

Fibrinous  bronchitis — symptoms  :  The  symptoms  are  those 
of  a  severe  catarrhal  bronchitis,  acute  or  chronic,  as  the  case 
may  be.  They  differ  mainly  in  the  severity  of  the  dyspnoea, 
which  in  the  croupous  variety  is  excessive. 

The  physical  signs  are  likewise  the  same. 

Diagnosis  :  This  is  made  by  the  expulsion  and  recognition 
of  the  fibrinous  casts  of  the  tubes.  Otherwise  the  diagnosis 
from  ordinary  bronchitis  is  impossible. 

Prognosis :  This  is  bad,  as  considerably  over  half  the  cases 
die. 

Fibrinous  bronchitis — treatment :  This  is  the  same  as  for  the 
catarrhal  variety.  Inhalations  of  oxygen  may  be  of  service 
in  the  excessive  dyspnoea.  If  the  diagnosis  of  the  fibrinous 
form  is  made,  an  emetic  may  assist  in  the  expulsion  of  the 
membrane. 

With  the  possibility  of  the  disease  being  diphtheritic  anti- 
toxin might  be  used  to  aid  in  loosening  the  cast. 

BKONCHO-PNEUMONIA. 

Synonyms  and  definition :  Other  names  for  this  common 
children's  disease  are  catarrhal  pneumonia,  lobular  pneu- 
monia, and  capillary  bronchitis. 

It  is  an  inflammation  involving  both  the  terminal  bron- 
chioles and  the  air-vesicles.  There  is  consequently  a  lobular 
distribution  to  this  inflammation. 

Etiology:  This  is  the  usual  "pneumonia"  of  childhood, 
it  maybe  primary,  as  after  exposure  to  cold,  or  damp,  or 
draughts  ;  but  is  more  commonly  secondary  to  bronchitis,  or 
measles,  or  whooping-cough,  or  diphtheria,  or  influenza.     It 


236  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

attacks  previously  healthy  children,  but  more  often  those  of 
feeble  constitution.  Micro-organisms  of  one  form  or  another 
are  the  actual  exciting  cause. 

Pathology  :  The  inflammation  involves  the  entire  thickness 
of  the  bronchial  wall,  and  not  the  mucous  membrane  only. 
The  terminal  bronchi  are  those  usually  attacked,  and  the  air- 
vesicles  connected  with  them  and  those  surrounding  them  are 
involved  in  the  inflammatory  process.  The  walls  are  thick- 
ened and  infiltrated  by  new  cells  ;  the  air-vesicles  are  filled 
with  exuded  fibrin,  pus,  and  epithelium,  and  in  places  this  is 
changed  into  new  connective  tissue.  Parts  of  both  lungs  are 
regularly  involved.  Catarrhal  bronchitis,  pleurisy,  atelectasis, 
and  diffuse  consolidation  of  portions  of  the  lungs  are  ordi- 
nary complications.  This  inflammation  is  such  that  resolu- 
tion is  slow,  and  often  it  may  become  chronic. 

Broncho-pneumonia — symptoms  :  The  disease,  whether  it  be 
primary  or  follow  a  preceding  inflammation  elsewhere,  begins 
gradually  with  a  slowly  rising  temperature,  an  increasing 
rapidity  of  the  pulse  and  respiration,  and  a  cough.  The  tem- 
perature runs  irregularly,  with  remissions  and  exacerbations, 
the  highest  point  reached  being  ordinarily  103°  or  104°  F. 
The  fever  subsides  gradually,  by  lysis. 

The  pulse  goes  to  130  to  150  beats  to  the  minute.  The  respi- 
ration is  excessively  rapid  and  shallow,  and  may  reach  50  to 
75  per  minute.  The  respiratory  rhythm  is  changed,  so  that 
the  breath  is  held  after  inspiration,  giving  the  so-called  grunt- 
ing respiration.  The  pulse-respiration  ratio  is  entirely  lost. 
The  cough  is  short  and  dry,  and  quite  incessant.  Later  it  is 
looser  and  easier,  but  expectoration  is  uncommon,  the  sputa 
being  swallowed. 

The  face  and  skin  are  suffused  and  cyanotic,  the  alee  nasi 
are  playing  freely.  The  tongue  is  coated  and  dry.  There 
may  be  vomiting  and  diarrhoea.  All  the  cases  are  restless, 
and  in  some  the  nervous  symptoms  are  especially  marked,  with 
delirium,  or  stupor  and  coma,  and  often  convulsions.  A  good 
many  cases  are  ushered  in  by  general  spasms.  Prostration  is 
marked  in  all  the  severe  cases. 

If  the  case  is  to  go  on  to  recovery,  a  gradual  improvement 
in  all  the  symptoms  occurs,  but  convalescence  is  extended  over 


BRONCHO-PNEUMONIA.  237 

a  considerable  time,  and  the  duration  of  the  attack  is  quite 
indefinite. 

In  other  cases  the  acute  symptoms  gradually  subside,  and 
the  disease  protracts  itself  into  a  chronic  state. 

The  bad  cases  increase  in  severity,  and  die  exhausted,  or 
from  respiratory  failure,  or  from  convulsions,  before  the 
second  week. 

Broncho-pneumonia — physical  signs:  If  only  the  walls  of 
the  bronchi  and  of  the  air-spaces  are  involved,  there  will  be 
no  physical  signs  at  all.  If  enough  neighboring  air-spaces 
are  inflamed  to  produce  patches  of  consolidation,  we  have 
areas  of  dullness  on  percussion,  increased  fremitus,  and  bron- 
chial voice  and  breathing. 

If  a  catarrhal  bronchitis  is  present  as  a  complication,  which 
is  very  common,  we  find  the  fine  or  coarse  mucous  rales  of  this 
disease.  The  smaller  and  the  finer  the  rales,  the  nearer  to 
the  air-vesicles  they  are  made,  and  the  more  the  probability, 
in  the  absence  of  signs  of  consolidation,  of  the  presence  of 
broncho-pneumonia. 

If  any  pleurisy  is  present,  we  find  crepitant  rales  or  a 
friction-rub. 

Diagnosis :  In  some  cases  the  diagnosis  must  be  made  by 
the  presence  of  fever,  rapid  breathing,  cough,  and  prostra- 
tion. 

Catarrhal  bronchitis  often  gives  exactly  the  same  signs,  but 
broncho-pneumonia  has  more  fever  and  more  prostration. 
Without  signs  of  areas  of  consolidation  the  differentiation 
cannot  be  positive. 

From  lobar  pneumonia  the  diagnosis  is  fairly  easy,  the 
history  and  physical  signs  of  the  two  being  quite  different. 

The  only  important  difficulty  is  in  excluding  tubercular 
broncho-pneumonia  in  the  protracted  cases.  This  should 
always  be  borne  in  mind,  but  often  only  time  will  decide  the 
question. 

Prognosis  :  A  serious  prognosis  must  always  be  given.  Cer- 
tain conditions  add  decidedly  to  the  mortality-rate.  These 
are  age  and  previous  condition  of  health.  The  younger  the 
infant  the  worse  the  prognosis.  Previous  disease,  as  measles, 
pertussis,  diphtheria,  or  influenza,  or  bad  nutritional  stales, 


238  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

as  rachitis,  add  to  the  dangers.  The  amount  of  lung  in- 
volved and  the  presence  of  a  large  amount  of  bronchitis  are 
elements  to  be  considered  in  estimating  any  particular  case. 

Broncho-pneumonia — treatment :  As  prophylaxis,  measures 
should  be  taken  in  all  cases  of  bronchitis  and  the  infectious 
diseases  to  prevent  the  development  of  broncho-pneumonia. 
Proper  attention  to  the  air  of  the  sick-room,  and  to  the  mouth 
and  throat,  and  to  the  treatment  of  these  diseases  will  pre- 
vent many  cases  of  broncho-pneumonia. 

If  the  disease  has  developed,  the  child  must  be  .put  to  bed 
in  a  room  with  an  equable  temperature  of  about  70°  F.,  and 
kept  on  easily  digestible  but  nutritious  diet.  Special  atten- 
tion should  be  given  not  to  overload  the  stomach.  The 
child  should  not  be  allowed  to  lie  in  one  position  for  any 
length  of  time,  as  this  favors  hypostatic  congestion  of  the 
lungs.  There  seems  to  be  some  value  in  keeping  the  air  in 
the  room  moist  by  allowing  water  to  boil  over  a  fire. 

The  child's  chest  should  be  rubbed  twice  a  day  with  cam- 
phorated oil  or  diluted  turpentine,  and  then  kept  covered  with 
a  cotton  jacket.  If  stronger  counter-irritation  is  needed, 
repeated  applications  of  mustard  paste  made  with  flour,  in 
strength  of  1  to  6  up  to  1  to  2,  may  be  used. 

In  the  beginning  of  the  disease  fractional  doses  of  calomel, 
frequently  repeated,  should  be  given.  Following  this,  doses 
of  ammonium  chloride  and  ipecac,  in  syrup  of  tolu,  or  simple 
elixir,  should  be  given  frequently  enough  to  keep  up  a  con- 
tinuous action  on  the  bronchial  mucous  membrane  but  not  to 
nauseate,  throughout  the  disease. 

Inhalations  of  tar  or  of  creosote  seem  to  have  some  value. 
Stimulants  will  usually  be  needed  after  the  disease  lias  run  a 
few  days.  Alcohol  and  strychnine  are  the  best.  Atropine 
may  be  used  to  stimulate  the  respiration. 

The  fever  will  seldom  need  any  treatment ;  but  if  it  should, 
cool  sponging  should  be  our  resource,  rather  than  antipyretics 
internally.  If  the  child  is  very  restless  and  the  nervous 
symptoms  are  marked,  small  doses  of  opium,  or  of  bromide, 
may  be  used.  As  a  rule,  the  less  opium  given  in  this  disease 
the  better.  In  sudden  attacks  of  collapse,  hypodermics  of 
caffeine,  or  of  camphor,  or  of  nitroglycerin,  may  be   used. 


LOBAR  PNEUMONIA.  239 

Immersion  in  hot  water  is,  however,  a  quicker  and  more  re- 
liable stimulant  than  drugs. 

If  the  disease  becomes  protracted,  attention  to  the  general 
health  and  a  change  of  climate  are  our  main  resources.  Iron, 
quinine,  and  cod-liver  oil,  as  general  tonics,  are  of  most  value. 
Creosote  should  also  be  given  in  slowly  increasing  doses. 

LOBAR  PNEUMONIA. 

Definition:  This  disease  is  also  called  croupous  or  fibrinous 
pneumonia,  and  while  broncho-pneumonia  is  the  ordinary 
variety  as  seen  in  children,  still  the  lobar  form  occurs  with 
more  frequency  in  them  than  is  usually  supposed. 

Etiology :  The  older  the  child  the  more  frequent  is  this 
form  of  pneumonia.  It  is  most  frequent  during  the  cold 
mouths  of  the  year.  It  is  due  in  the  large  number  of  cases 
to  the  presence  of  the  diplococcus  pneumoniae.  The  disease 
at  times  seems  to  be  somewhat  epidemic. 

Pathology  :  The  lower  lobe  of  one  or  the  other  lung  is  most 
often  involved,  although  the  upper  lobe  may  be  attacked.  At 
times  more  than  one  lobe  in  the  same  lung  is  affected,  or  even 
parts  of  both  lungs. 

The  disease  goes  through  the  same  stages  as  in  adults,  first 
that  of  congestion,  in  which  in  the  affected  lobe  the  air-cells 
contain  the  products  of  inflammation,  and  their  walls  are 
swollen  and  thickened. 

The  second  stage — of  red  hepatization — follows,  in  which 
the  above  process  is  simply  so  intensified  as  to  cause  a  com- 
plete consolidation  of  the  affected  part.  This  is  red,  and  re- 
sembles liver  on  cut  section.  During  this  stage  the  pleura  over 
the  affected  lobe  becomes  inflamed  and  is  coated  with  fibrin. 

This  is  followed  by  the  third  stage — that  of  gray  hepatiza- 
tion—in  which  the  inflammatory  exudate  begins  to  soften  and 
break"  down.  The  red  color  is  changed  to  gray,  but  the  con- 
solidation remains. 

Lastly  conies  the  stage  of  resolution,  in  which  the  exudates 
become  still  softer  and  more  liquid,  and  are  gradually 
removed  by  absorption  and  expectoration.  After  this  stage 
is  passed  the  lung  returns  to  its  original  condition. 


240  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Lobar  pneumonia — symptoms :  The  disease  begins  quite 
suddenly  with  chilly  sensations,  a  rapid  rise  in  temperature, 
pain  in  the  chest,  and  cough.  In  many  cases  the  onset  is 
announced  by  convulsions  or  vomiting. 

The  temperature  soon  reaches  about  105°  F.,  and  remains 
there  with  very  slight  remissions  until  the  disease  is  over, 
when  it  falls  quickly,  by  crisis.  The  respiration  is  acceler- 
ated to  40  or  50  per  minute,  and  is  usually  painful.  The  pulse 
becomes  rapid,  120  to  140  per  minute,  but  should  be  strong 
and  full.  The  appetite  is  lost,  and  the  bowels  may  be  loose  or 
constipated.  There  is  apt  to  be  rather  a  lively  delirium 
throughout  the  fever.  The  cough  is  persistent  and  frequently 
painful.  In  the  beginning  the  expectoration,  if  not  swallowed, 
is  a  stringy,  sticky,  blood-stained  mucus ;  later  it  grows 
looser,  and  consists  of  little  yellowish  lumps.  Daring  the 
whole  course  of  the  disease  the  child  sleeps  very  little. 

The  disease  lasts  with  very  little  change  in  its  character 
for  a  week  or  ten  days,  when  the  temperature  rapidly  drops 
to  normal  by  the  so-called  crisis.  With  the  fall  in  tempera- 
ture is  a  coincident  drop  in  the  rate  of  the  pulse  and  respi- 
ration to  nearly  normal.  In  some  cases  is  a  pseudo-crisis  with 
some  fall  of  temperature  and  remission  in  the  symptoms  a 
day  or  so  preceding  the  real  crisis.  It  is  just  before  the  crisis 
that  the  sudden  attacks  of  heart-failure,  that  are  such  a 
serious  feature  of  lobar  pneumonia,  develop.  Some  cases, 
instead  of  defervescing  at  the  regular  time,  go  on  with  the 
same  symptoms,  this  indicating  usually  a  spreading  of  the 
disease  to  new  portions  of  the  lungs. 

Lobar  pneumonia — physical  signs :  During  the  congestive 
stage  there  is  slight  dulness  on  percussion,  while  the  breath- 
and  voice-sounds  are  somewhat  exaggerated.  Over  the  same 
area  a  few  crepitant  rales  are  usually  heard. 

During  the  stages  of  hepatization  there  is  distinct  dulness  on 
percussion  over  the  consolidated  area.  The  vocal  fremitus 
is  markedly  increased,  and  both  the  breathing  and  the  voice 
are  bronchial.     Rales  are  usually  absent. 

As  the  stage  of  resolution  appears  the  dulness  diminishes, 
the  breathing  and  voice  gradually  take  on  their  normal 
quality,  and  the  crepitant  rdle,  the  rdle  redux,  returns.     Later, 


INTERSTITIAL  PNEUMONIA.  241 

coarser  rales  take  their  place,  and  are  present  until  the  lungs 
return  to  normal. 

Signs  of  dry  pleurisy,  or  of  fluid  in  the  chest,  or  of  peri- 
carditis, are  often  found  as  complications. 

Diagnosis :  Broncho-pneumonia  and  pleurisy  with  effusion 
are  the  two  diseases  most  likely  to  be  confused  with  lobar 
pneumonia.  The  history  and  physical  signs,  if  carefully  fol- 
lowed, will  usually  prevent  any  error  being  made. 

Prognosis :  The  prognosis  in  children  is  much  better  than 
in  adults.  The  great  danger  depends  on  failure  of  the  heart, 
and  in  children  this  does  not  occur  so  readily  as  in  adults. 
The  height  of  the  temperature  and  the  extent  of  lung  in- 
volved are  of  great  importance  in  estimating  the  prognosis. 
The  danger  of  post-pneumonic  complications,  particularly 
pleurisy  with  effusion  and  empyema,  must  be  remembered. 

Lobar  pneumonia — treatment:  The  child  should  be  kept 
absolutely  quiet  in  bed  from  the  first.  The  food  should  be 
liquid,  and  given  in  small  quantities  frequently  repeated. 

If  there  is  pain  in  the  chest,  the  application  of  mustard 
paste  and  a  cotton  jacket  are  of  value.  For  the  restlessness 
and  cough,  small  doses  of  opium  are  allowable.  For  the  tem- 
perature it  is  best  to  do  nothing.  If  its  height  seems  detri- 
mental to  the  child,  cool  sponging  is  the  best  way  of  bringing 
it  down.  If  the  heart's  action  is  too  excessive,  small  doses 
of  aconite  may  be  given.  The  main  reliance  must  be  put  on 
heart-stimulants.  They  will  always  be  necessary  just  before 
the  crisis,  and  had  better  be  used  in  moderation  throughout 
the  disease.  The  best  of  these  are  alcohol  and  strychnine. 
Digitalis  is  often  used,  but  is  not  so  reliable  as  the  above. 
They  should  be  used  in  full  dose.  The  inhalation  of  oxygen 
is  useful  in  certain  cases  of  excessive  clyspnaa.  During  con- 
valescence, general  tonic  treatment  is  indicated. 

INTERSTITIAL  PNEUMONIA. 

Definition:  This  condition  is  also  called  chronic  broncho- 
pneumonia and  fibroid  .phthisis.  Clinically  it  is  a  rather  in- 
definite disease  and  difficult  of  diagnosis. 

Etiology:    It    follows   attack-    of    broncho-pneumonia,   of 

16— D,  C. 


242  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

chronic  pleurisy,  and  of  bronchitis.  Its  connection  with  a 
precedent  cured  tuberculosis  is  in  doubt.  It  is  a  compara- 
tively rare  disease  of  childhood. 

Pathology :  The  disease  is  regularly  unilateral,  and  consists 
in  a  substitution  of  connective  tissue  for  the  normal  pul- 
monary tissue  throughout  the  affected  lung.  The  pleura  on 
the  lung  is  thickened  and  adherent,  and  the  lung  is  filled 
with  bands  of  dense  fibrous  tissue.  In  fact,  there  is  a  growth 
of  new  connective  tissue  all  through  the  lung.  The  walls  of 
the  bronchi  are  thickened  or  thinned,  and  in  places  the 
bronchi  are  much  dilated,  forming  bronchiectases. 

Interstitial  pneumonia — symptoms:  Following  the  history 
of  the  acute  disease  is  the  persistence  of  the  symptoms  of 
cough,  expectoration,  dyspnoea  on  exertion,  and  at  times  pain 
in  the  chest.  The  patient  does  not  gain  in  flesh  or  strength, 
but  remains  thin  and  feeble.  The  cough  is  troublesome 
and  the  expectoration  usually  profuse  and  muco-purulent. 
Haemoptysis  may  be  present.  Fever  is  ordinarily  not  pres- 
ent. The  disease  lasts  for  months  and  years.  If  only  a 
small  area  of  the  lung  is  involved,  the  inflammation  may 
stop,  and  the  patient  recover.  If  the  whole  lung  is  involved, 
the  patient  will  probably  die,  exhausted,  after  a  long  time. 
Often  a  tubercular  inflammation  is  engrafted  on  the  inter- 
stitial change. 

Interstitial  pneumonia — physical  signs :  These  are  not  dis- 
tinctive. The  chest  is  retracted.  There  is  dulness  on  per- 
cussion, or  flatness.  The  vocal  fremitus  is  increased.  The 
breathing-sounds  are  feeble,  or  bronchial,  or  cavernous  in  cases 
where  bronchiectatic  cavities  are  found.  Various  forms  of 
rales  are  usually  present. 

Diagnosis :  The  diagnosis  of  this  disease  from  tuberculosis 
is  of  special  importance,  and  is  extremely  difficult  to  make. 
The  history  and  physical  signs  of  the  two  diseases  are  almost 
identical.  The  diagnosis  usually  rests  on  frequent  examina- 
tions of  the  sputa  for  tubercle  bacilli. 

Prognosis:  This  is  bad.  Some  cases  with  an  involvement 
of  only  a  small  area  of  lung  recover.  Life  may  be  prolonged 
over  very  many  years. 

Interstitial  pneumonia— treatment :  Climatic  and  hygienic 


PULMONARY  EMPHYSEMA— ASTHMA.  243 

treatment  are  of  special  value,  and  the  only  ones  on  which 
we  can  place  much  reliance.  The  child  should  live  where  he 
can  be  out  of  doors  most  of  the  time.  Cod-liver  oil  and 
creosote  seem  to  have  some  value. 

PULMONARY  EMPHYSEMA. 

Definition :  The  variety  occurring  regularly  in  children  is 
the  so-called  vesicular  emphysema,  in  which  the  air-spaces  are 
abnormally  dilated,  but  without  any  of  the  chronic  inflam- 
matory changes  seen  in  adult  life. 

Etiology :  The  cause  is  either  compensatory,  in  which  por- 
tions of  the  lung  are  overdistended,  because  other  parts  are 
disabled  ;  or  obstructive,  where  something  mechanically  pre- 
vents the  lung  from  emptying  itself  properly.  In  other 
words,  emphysema  in  children  rarely  exists  unless  compli- 
cated by  some  other  form  of  disease  in  the  lung. 

Pathology :  The  causative  disease  produces  its  lesions,  and 
in  the  parts  affected  by  emphysema  the  air-spaces  are  found 
dilated  and  their  walls  thinned.    In  some  the  walls  are  ruptured. 

Pulmonary  emphysema — symptoms :  There  are  no  distinc- 
tive svmptoms  of  this  disease,  as  those  of  the  primary  condi- 
tion completely  conceal  any  slight  ones  that  might  be  produced 
by  the  emphysema.  Dyspnoea,  persistent  or  in  attacks,  be- 
longs to  this  disease,  but  is  regularly  present  before  the  em- 
physema develops. 

Pulmonary  emphysema — physical  signs  :  These  arc  likewise 
liable  to  be  concealed  by  the  primary  disease.  The  emphysem- 
atous areas  give  a  tympanitic  percussion-note,  with  feeble 
breathing-sounds  and  prolonged,  low-pitched  expiration. 

Diagnosis:  This  is  rarely  made  in  dealing  with  children. 

Prognosis:  If  the  original  disease  is  cured,  the  emphysema 
is  regularly  recovered  from  also. 

Treatment:  This  is  that  of  the  original  disease.  There  are 
no  special  measures  for  the  emphysema  itself. 

ASTHMA. 

Definition:  This  is  also  called  bronchial  or  spasmodic 
asthma.     It  is  a  paroxysmal  dyspnoea  in  which,  (luring  the 


244  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

intervals  between  the  paroxysms,  no  evidences  of  disease  of 
the  lungs  are  present. 

Etiology :  The  disease  occurs  with  some  frequency  among 
older  children,  and  seems  specially  to  attack  those  of  a  gouty 
or  neurotic  heredity.  The  disease  is  looked  on  as  a  vaso- 
motor neurosis  without  lesion,  but  in  certain  cases  the  presence 
of  some  abnormality  in  some  part  of  the  respiratory  tract 
seems  to  act  as  the  exciting  cause.  Hypertrophied  turbinates, 
adenoids,  enlarged  tonsils,  elongated  uvula,  bronchitis,  or  en- 
larged bronchial  glands  are  such  causes.  The  inhalation  of 
irritants  as  in  hay-fever,  and  gastro-intestinal  disturbances 
often  provoke  an  attack. 

Asthma — symptoms  :  The  attack  regularly  comes  on  sud- 
denly without  warning,  and  often  in  the  night.  It  consists 
of  intense  dyspnoea  and  air- hunger.  The  child  sits  up  or 
stands  bracing  its  arms,  to  bring  into  play  the  accessory  mus- 
cles of  respiration.  The  skin  becomes  bluish,  the  eyes  promi- 
nent, and  the  alse  nasi  widely  dilated.  The  skin  may  be  cov- 
ered with  perspiration.  The  respiration  is  noisy  and  wheezing, 
and  the  rate  is  rather  under  than  above  normal.  The  pulse 
is  rapid  and  small,  and  the  temperature  ordinarily  normal. 

After  a  few  hours  the  attack  gradually  subsides  and  the 
respiration  becomes  regular  and  easy,  and  the  patient  drops 
to  sleep  exhausted.  At  times  the  attack  lasts  days  instead 
of  hours.     Recurrences  are  to  be  expected. 

Asthma — physical  signs :  The  chest  is  found  fairly  fixed. 
On  percussion  there  is  a  rather  hyperresonant  note.  The  in- 
spiration is  short  and  jerky  ;  the  expiration  is  very  prolonged 
and  wheezing.  The  whole  chest  is  full  of  sibilant  and  sonor- 
ous breathing.     If  bronchitis  exists,  moist  rales  are  heard. 

Diagnosis :  This  is  not  difficult,  After  the  attack  is  over 
a  searching  examination  of  the  heart,  kidneys,  lungs,  and 
upper  air-passages  should  be  made  to  determine  the  cause  if 
possible. 

Prognosis :  The  paroxysm  is  almost  invariably  recovered 
from.  The  prognosis  for  complete  recovery  from  the  attacks 
is  fairly  good,  especially  if  climatic  treatment  can  be  taken 
advantage  of. 

Asthma — treatment :  During  the  paroxysms  the  best  treat- 


PULMONARY  GANGRENE.  245 

ment  is  the  inhalation  of  the  fumes  of  saltpetre  paper,  or  of 
the  smoke  of  stramonium  cigarettes.  A  hypodermic  of  a 
small  dose  of  morphine  and  atropine  will  cut  short  an  attack, 
but  had  better  not  be  used  except  under  exceptional  circum- 
stances. 

Between  attacks  the  child  should  be  put  in  the  best  hygienic 
condition  and  kept  in  a  good  climate.  Any  abnormalities  in 
the  respiratory  tract  should  be  carefully  treated.  As  drugs, 
belladonna,  iodide  of  potassium,  and  cod-liver  oil  are  of 
most  value.  Antipyrine  and  chloral  in  small  doses  regularly 
seem  to  have  a  good  effect  in  some  cases. 

PULMONARY  GANGRENE. 

This  is  a  localized  necrosis  of  the  pulmonary  tissue,  and  is 
rare  under  all  circumstances,  being  rather  commoner  in  chil- 
dren than  in  adults. 

Etiology :  It  is  almost  invariably  secondary  to  pneumonia, 
septic  infections,  or  some  equally  intense  inflammation  in  the 
lung.     It  is  seen  usually  in  children  of  feeble  constitution. 

Pathology :  The  process  may  be  circumscribed  or  diffuse. 
The  gangrenous  patches  are  greenish-looking  and  emit  an  in- 
tensely foul  odor.  There  is  regularly  found  a  thrombosis  of 
the  vessels  leading  to  the  necrotic  mass,  and  this  is  conse- 
quently wedge-shaped.  Putrefactive  bacteria  are  present 
in  large  numbers.  If  the  gangrene  is  on  the  surface,  as  it 
usually  is,  there  is  regularly  present  a  complicating  pleurisy. 

Pulmonary  gangrene — symptoms :  Those  of  the  primary 
disease  are  always  present  and  mask  the  symptoms  of  gan- 
grene. The  distinctive  features  of  this  condition  are  the 
gangrenous  odor  of  the  breath  and  the  expectoration  of  necrotic 
masses  of  tissue  from  the  lungs.  Irregular  fever,  sweating, 
cough,  and  emaciation  are  present,  but  do  not  point  especially 
to  gangrene. 

Physical  signs:  There  may  be  only  the  signs  of  bronchitis, 
or  of  consolidated  lung,  or  of  a  cavity — none  of  them  dis- 
tinctive. 

Diagnosis:  This  is  very  difficult,  and  can  only  be  surmised 
unless  in  the  presence  of  the  two  characteristic;  features  of  the 


246  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

disease,  the  odor  of  the  breath  and  the  peculiar  expectora- 
tion. 

Prognosis  :   This  is  bad.     Death  is  the  usual  result. 

Pulmonary  gangrene — treatment :  Proper  nourishment  and 
stimulants  of  the  alcoholic  variety  are  the  methods  of  value. 
The  inhalation  of  the  fumes  of  turpentine,  or  creosote,  dis- 
guises the  foul  odor  of  the  breath. 

PULMONARY  ATELECTASIS. 

Definition :  This  is  a  condition  in  which  from  different 
causes  the  alveoli  of  the  lung  collapse  and  return  to  their  foetal 
condition  of  non-aeration. 

Etiology :  It  occurs  especially  in  feeble  children,  and  in 
those  suffering  from  the  various  congenital  and  acquired 
forms  of  malnutrition.  The  actual  causes  are  compression 
or  obstruction.  Such  conditions  as  effusions  in  the  pleural  or 
pericardial  sacs,  deformities  of  the  spine  or  thorax,  and 
tumors  in  the  cavity  of  the  chest  may  act  to  cause  atelectasis 
from  compression.  The  obstructive  causes  are  those  which 
occlude  a  small  or  large  bronchus.  The  swollen  mucous 
membrane,  the  increased  mucous  secretion,  and  the  feeble 
breathing  are  all  to  be  taken  into  account  in  this. 

Pathology :  The  collapsed  areas  may  be  scattered  through 
the  lung,  but  are  usually  situated  in  the  posterior  portion  and 
near  the  spine.  The  area  involved  is  darker  than  the  rest  of 
the  lung,  and  is  somewhat  depressed  below  its  surface.  If 
put  in  water,  it  sinks.  The  surrounding  alveoli  are  apt  to  take 
on  a  condition  of  compensatory  emphysema. 

Symptoms :  Dyspnoea  and  cyanosis  are  the  ordinary  symp- 
toms of  pulmonary  atelectasis,  but  as  it  usually  occurs  com- 
plicating some  other  condition,  the  symptoms  of  the  two 
blend,  and  are  not  characteristic.  The  circulation  is  poor, 
the  extremities  are  cold,  and  the  child  is  usually  in  a  con- 
dition of  collapse. 

Pulmonary  atelectasis — physical  signs :  The  respiratory 
murmur  over  the  affected  area  is  feeble,  and  fine  rales  are 
usually  heard  in  the  neighborhood.  On  percussion,  dulness 
is  regularly  present  over  the  collapsed  area  if  it  is  of  any 


DRY  PLEURISY.  247 

size.  The  physical  signs  of  the  complicating  condition  must 
always  be  taken  into  consideration. 

Diagnosis :  Except  when  a  large  continuous  area  of  lung  is 
involved,  the  condition  is  seldom  recognized.  Even  if  its 
presence  be  suspected,  a  positive  diagnosis  can  seldom  be 
made. 

Prognosis  :  This  is  serious,  as  it  regularly  occurs  in  feeble 
infants  who  are  already  suffering  from  another  disease. 

Pulmonary  atelectasis — treatment :  In  addition  to  the  care 
of  the  primary  disease,  stimulants,  fresh  air,  oxygen,  and 
very  hot  baths  seem  of  most  service. 

DRY  PLEURISY. 

This  form  of  pleurisy  is  the  simplest,  and  is  accompanied 
by  the  exudation  of  fibrin  only. 

Etiology  :  It  follows  exposure  to  cold  and  wet  and  injuries  to 
the  chest,  and  is  secondary  to  various  inflammations  in  the  lung. 

Pathology:  The  inflammation  may  begin  in  the  pulmonary 
or  costal  pleura,  but  regularly  spreads  to  the  opposite  por- 
tion. The  inflamed  area,  be  it  a  small  or  large  one,  is 
swollen,  red,  and  coated  with  fresh  fibrin.  Bands  of  this 
fibrin  form  adhesions  between  the  opposite  pleural  surfaces. 

After  the  inflammation  subsides  the  fibrin  may  be  com- 
pletely absorbed,  but  permanent  adhesions  are  usually  left. 

Dry  pleurisy — symptoms  :  There  is  a  sharp,  cutting  pain 
over  the  affected  area,  made  worse  by  pressure  or  by  inspira- 
tion. There  are  also  a  dry,  useless  cough,  and  general 
malaise.  The  symptoms  usually  last  about  a  week,  when  they 
completely  disappear. 

Dry  pleurisy — physical  signs  :  Over  the  affected  area  is 
heard  ;i  friction-sound,  or  fine  crepitant  rdles.  These  sounds 
arc  developed  by  full  inspiration,  and  are  unchanged  by 
coughing. 

Diagnosis:  This  is  easy  with  the  history  and  physical  signs. 
The  presence  of  complications  in  the  lungs  must  always  be 
thought   of. 

Prognosis:  In  uncomplicated  cases  this  is  good,  although  a 
damaged  pleura  is  regularly  lefl  behind. 


248         DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Dry  pleurisy — treatment :  Counter-irritation  in  the  form  of 
mustard  paste,  iodine,  or  even  a  blister,  hurries  on  the  proc- 
ess. Rest  in  the  form  of  a  firm  bandage  around  the  chest 
will  often  ease  the  pain.  Opium  may  be  needed.  Some 
simple  febrile  mixture,  as  phenacetin,  together  with  confine- 
ment to  the  house,  is  useful. 

PLEURISY  WITH  EFFUSION. 

Definition :  In  this  form  of  pleurisy  the  side  of  the  thorax 
involved  contains  more  or  less  serum  in  addition  to  the 
fibrin. 

Etiology  :  It  follows  exposure  to  cold  and  damp.  It  is 
often  secondary  to  pneumonia,  rheumatism,  or  nephritis.  It 
is  frequently  tubercular. 

Pathology :  Only  one  pleural  cavity  is  regularly  involved, 
but  cases  are  occasionally  seen  on  both  sides  at  once.  The 
pleura  is  coated  with  fibrin,  and  bands  of  this  material  form 
fresh  adhesions  between  the  two  surfaces.  The  cavity  con- 
tains more  or  less  serum,  which  may  be  quite  clear,  or  slightly 
turbid,  or  at  times  sanguinolent.  In  the  largest  effusions  the 
lung  is  compressed  in  the  upper  and  posterior  part  of  the 
chest.  After  the  inflammation  subsides  the  serum  is  regu- 
larly absorbed,  but  adhesions  are  apt  to  be  left  behind. 

Pleurisy  with  effusion — symptoms :  If  the  disease  is  sec- 
ondary, the  symptoms  of  the  primary  disease  gradually 
merge  into  those  of  the  pleurisy.  If  the  pleurisy  is  primary, 
it  at  times  begins  acutely  with  high  fever,  pain  in  the  chest, 
cough,  and  prostration.  The  regular  onset,  though,  is  gradual, 
with  slight  fever,  general  malaise,  and  often  no  symptoms  at 
all  pointing  definitely  to  the  chest. 

After  any  form  of  onset  the  disease  regularly  takes  on  a 
subacute  course,  the  temperature  only  a  little  above  normal, 
with  some  pain  in  the  chest,  and  cough  and  dyspnoea  on  exer- 
tion. The  patient  feels  sick,  but  often  not  enough  to  go  to 
bed,  and  there  are  anorexia  and  loss  of  flesh  and  strength. 

The  disease  if  left  alone  lasts  weeks  or  months,  and  has  a 
tendency  to  spontaneous  recovery.  Some  few  die  from  press- 
ure of  a  very  large  effusion.     In   some  the  effusion  becomes 


PLEURISY   WITH  EFFUSION.  249 

purulent,  and  the  patient  has  empyema.  In  others,  the  pleu- 
risy being  tubercular  is  not  recovered  from,  and  later  the 
child  shows  evidences  of  tuberculosis  elsewhere. 

Pleurisy  with  effusion — physical  signs  :  Before  the  effusion 
is  marked,  and  as  it  is  absorbed,  friction-sounds  are  heard  over 
the  inflamed  pleura.  After  the  fluid  is  present,  we  find  beloiu 
its  level  flatness  on  percussion,  diminished  or  absent  breath-  and 
voice-sounds,  and  loss  of  vocal  fremitus.  At  the  level  of  the 
fluid  the  voice  has  the  tremulous  quality  known  as  a>,gophony. 
Above  the  fluid  the  resonance  is  exaggerated  and  the  breath- 
ing is  broncho-vesicular,  due  to  the  compressed  lung.  The 
chest  containing  the  fluid  does  not  move  in  respiration,  the 
intercostal  spaces  bulge,  the  diaphragm  is  depressed,  and  when 
the  fluid  is  on  the  left  side  the  heart  is  displaced 

Irregular  physical  signs  are  frequently  present ;  and  in  many 
cases  where  the  fluid  is  sacculated  by  adhesions  they  become 
very  perplexing. 

Diagnosis :  The  physical  signs  in  a  typical  case  are  very 
positive,  but  so  often  irregular  signs  are  found  that  various 
forms  of  inflammation  in  the  lungs  may  be  confused  with  an 
effusion.  From  empyema  the  diagnosis  can  only  be  made  by 
the  use  of  an  exploring-needle.  Under  any  circumstances, 
the  exploring-needle  had  better  be  used,  in  order  to  establish 
the  diagnosis  positively. 

Prognosis  :  Recovery  is  the  rule.  The  two  dangers  are  the 
possibility  of  the  disease  changing  to  an  empyema,  and  of  its 
being  a  tubercular  pleurisy. 

Pleurisy  with  effusion — treatment :  The  patient  should  be 
put  to  bed,  on  a  diet  in  which  liquids  are  restricted,  and  some 
form  of  counterirritation  should  be  applied  to  the  chest. 
Dry  cups  or  blisters  are  often  very  useful  here.  The  bowels 
should  be  kept  freely  open,  and  by  means  of  diuretics  the 
kidneys  should  be  kept  secreting  in  abundance.  The  citrate 
•  'I'  potassium  and  digitalis  are  good  drugs  for  this  purpose.  If 
pain  is  excessive,  opium  may  be  used.  The  salicylate  of 
sodium  affects  some  cases  favorably. 

If  the  effusion  is  so  large  as  to  embarrass  the  breathing,  or 
if  it  does  not  decrease  under  the  above  treatment,  aspiration 
of  at  least  half  the  fluid   in  the  chest  should   be   performed 


250  DISEASES   OF  THE  RESPIRATORY  SYSTEM. 

under  aseptic  precautions.     A  second  and  a  third  aspiration 
are  sometimes  necessary. 

After  recovery,  general  tonic  treatment,  with  a  change  of 
climate  for  a  time,  should  be  undertaken. 

EMPYEMA. 

Definition :  This  is  a  disease  of  some  frequency  in  child- 
hood, and  consists  in  an  inflammation  of  the  pleura  with  a 
purulent  effusion. 

Etiology :  Most  of  the  cases  are  secondary  to  pneumonia. 
Some  follow  serous  pleurisy.  Others  complicate  the  infec- 
tious diseases,  or  are  part  of  a  general  sepsis.  Trauma  of 
the  chest,  or  direct  infection  of  the  pleura  from  a  necrotic 
rib  or  carious  vertebra  or  suppurating  gland,  are  other 
causes. 

One  of  three  general  varieties  of  bacteria  are  regularly  found 
in  the  pus — the  pneumococcus,  the  streptococcus,  or  the  tuber- 
cle bacillus.     Mixed  infections  are  also  found. 

Pathology :  The  whole  of  one  pleura  may  be  involved,  or 
only  a  circumscribed  portion.  Rarely  both  pleural  cavities 
may  be  simultaneously  attacked.  The  pleura  is  inflamed  and 
its  surface  coated  with  fibrin  and  pus,  and  the  cavity  is  more 
or  less  filled  with  a  purulent  exudate.  The  pus  settles  to  the 
bottom  of  the  pleural  sac,  and  floats  the  lung  upward  and 
toward  the  spine.  Adhesions  between  opposing  surfaces  of 
the  pleura  are  frequent,  causing  the  pus  to  be  sacculated. 

There  is  very  little  tendency  to  absorption  ;  and  if  un- 
treated, the  pus  tends  to  rupture  into  the  lung,  or  externally 
through  an  intercostal  space. 

Empyema — symptoms  :  Following  the  symptoms  of  the  pre- 
cedent pneumonia  or  infectious  disease,  the  temperature  con- 
tinues high  ;  there  may  be  sweats,  the  child  has  pain  in  the 
chest,  dyspnoea,  and  cough.  As  the  disease  advances,  the 
symptoms  are  mainly  those  of  infection — irregular  high  fever, 
sweating,  loss  of  flesh  and  strength,  anorexia,  diarrhoea,  pros- 
tration, and  a  rapidly  growing  anaemia.  The  pulse  grows 
rapid  and  feeble,  and  a  typhoid  condition  is  developed  if  the 
case  is  left  alone. 


EMPYEMA.  251 

The  disease  may  run  a  slow  course,  with  the  above  symp- 
toms more  or  less  intensified ;  and  if  untreated,  the  pus  may 
rupture  externally  or  through  the  lung,  or  the  patient  may 
die  exhausted  by  the  disease. 

Empyema — physical  signs :  These  are  identical  with  those 
of  pleurisy  with  effusion,  except  that  sacculation  of  the  pus 
is  more  common,  and  therefore  irregular  physical  signs  more 
to  be  expected. 

Diagnosis :  This  is  a  very  easy  disease  to  overlook  in  chil- 
dren. Pleurisy  with  effusion,  pneumonia,  and  phthisis  are 
likely  to  be  confounded  with  it.  It  is  always  advisable  in 
suspected  cases  to  make  use  of  the  exploring-needle. 

Prognosis  :  In  the  cases  following  pneumonia,  under  proper 
treatment,  the  prognosis  is  good.  In  the  cases  due  to  strepto- 
cocci the  prognosis  is  much  worse.  In  those  due  to  tubercle 
bacilli  the  prognosis  is  that  of  tuberculosis  in  general.  The 
younger  the  child  and  the  longer  the  disease  has  been  un- 
treated, the  worse  the  prognosis.  Some  few  cases  recover 
spontaneously.  The  prognosis  depends  very  decidedly  on  the 
treatment. 

Empyema — treatment :  The  child  should  be  put  on  tonic 
stimulating  treatment. 

The  empyema  requires  surgical  care  and  removal  of  the 
pus.  Aspiration  is  unsatisfactory,  and  is  best  reserved  for 
use  as  a  temporary  measure  only. 

Simple  incision  through  one  of  the  lower  intercostal  spaces, 
with  evacuation  of  the  pus  and  drainage  by  a  large-sized  tube, 
will  cure  most  of  the  cases.  General  or  local  anaesthesia  may 
be  used,  and  the  dressings  changed  frequently.  Irrigation 
had  better  not  be  employed. 

In  cases  where  the  ribs  are  close  together,  or  where  the  pus 
is  thick  and  fibrinous,  a  small  piece  of  one  rib  had  better 
he  resected,  and  the  subsequent  treatment  be  carried  out  as 
after  simple  incision.  Although  this  operation  is  more  severe, 
success  is  more  certain  alter  it  than  after  any  other  method  of 
treatment. 

In  the  few  oases  in  which  the  lung  will  not  expand  after 
evacuation  of  the  pus,  and  after  lapse  of  some  weeks,  exten- 
sive operations  with  resection  of  many  ribs  may  be  necessary. 


252         DISEASES  OE  THE  RESPIRATORY  SYSTEM. 

Pulmonary  gymnastics  should  be  advised  to  encourage  the 
expansion  of  the  lungs. 


ACUTE  PULMONARY  TUBERCULOSIS. 

This  form  of  tubercular  inflammation  in  the  lung  is  also 
called  acute  or  galloping  consumption,  or  acute  tubercular  bron- 
cho-pneumonia. It  is  seen  with  some  frequency  in  young 
children. 

Etiology  :  The  causes  are  predisposing  and  exciting.  The 
predisposition  is  often  inherited  from  a  tuberculous  family. 
Bad  hygienic  surroundings,  poor  food,  bad  air,  and  wasting 
diseases  produce  a  predisposition.  The  infectious  diseases, 
particularly  whooping-cough,  measles,  and  la  grippe,  and 
simple  inflammations  in  the  lung,  are  marked  predisposing 
causes.  The  exciting  cause  is  infection  by  the  tubercle  bacilli 
of  Koch,  which  in  most  cases  gain  access  to  the  victim  by  way 
of  the  respiratory  tract.  In  rarer  cases  they  are  taken  in  with 
the  food  or  drink,  and  at  times  by  direct  inoculation.  In 
only  a  very  few  cases  has  evidence  of  actual  intra-uterine  in- 
fection or  of  congenital  tuberculosis  been  proved.  In  any 
pulmonary  case  the  bronchial  lymph-glands  are  regularly 
the  seat  of  bacilli,  and  from  them  the  pulmonary  infection 
comes. 

Pathology :  The  lungs  are  more  or  less  filled  with  miliary 
tubercles.  These  are  scattered  irregularly  through  the  pul- 
monary tissue,  and  are  also  found  on  the  surface.  They  are 
apt  to  have  the  distribution  of  an  ordinary  broncho-pneu- 
monia, but  in  places  may  be  massed  together  in  lumps.  Some 
of  the  nodules,  if  the  case  is  not  too  recent,  caseate  and  break 
down  with  the  formation  of  cavities. 

Catarrhal  bronchitis,  simple  broncho-pneumonia,  or  even 
diffuse  consolidation  of  the  lung  may  exist  as  complications. 
The  pleura  is  regularly  involved  if  the  tubercular  process  is 
near  the  surface.  The  bronchial  glands  will  be  found  en- 
larged and  caseous. 

Acute  pulmonary  tuberculosis — symptoms :  The  onset  and 
symptoms  of  this  disease  are  almost  identical  with  those  of 
ordinary  broncho-pneumonia.     There  is  fever  of  a  somewhat 


ACUTE  PULMONARY   TUBERCULOSIS.  253 

irregular  character,  and  varying  from  101°  F.  to  104°  F. 
Sweats  are  not  frequent.  The  child  has  a  cough,  with  rapid 
respiration  and  pulse,  appears  quite  sick,  and  shows  a  loss  of 
flesh  and  strength  somewhat  more  marked  than  in  simple 
broncho-pneumonia.  Expectoration,  as  always  in  children, 
is  lacking. 

Some  of  the  cases  go  on  acutely  with  these  symptoms  and 
die  within  a  month.  Others  take  on  a  more  subacute  char- 
acter and  last  for  two  or  three  months,  but  the  tendency  in 
them  all  is  to  exhaustion  and  death. 

Acute  pulmonary  tuberculosis — physical  signs  :  Here  again 
the  similarity  with  the  signs  of  a  simple  bronchitis  or  broncho- 
pneumonia is  most  marked.  If  only  scattered  miliary  tuber- 
cles are  present,  with  the  accompanying  catarrhal  bronchitis, 
we  find  scattered  suberepitant  or  coarse  rales.  If  areas  of 
consolidation  are  present,  we  find  dulness,  increased  fremitus, 
and  broncho-vesicular  or  bronchial  breathing  and  voice.  In 
other  words,  there  is  nothing  distinctive  in  the  signs. 

Diagnosis :  The  history  and  physical  signs  are  so  nearly 
identical  with  those  of  simple  broncho-pneumonia  that  a 
positive  diagnosis  is  almost  impossible.  Unfortunately  we 
have  not  the  aid  of  finding  tubercle  bacilli  in  the  sputum  as 
in  adults,  as  sputum  is  so  hard  to  obtain.  The  family  history, 
the  preceding  condition,  and  the  surroundings  of  the  child 
should  all  be  carefully  taken  into  consideration.  Enlarged 
glands,  or  history  of  disease  of  the  bones,  are  especially  im- 
portant. 

The  loss  of  flesh  in  tubercular  pneumonia  is  more  marked 
than  in  the  simple  form.  The  signs  in  the  tubercular  variety 
arc  more  often  in  the  upper  lobes  or  anterior  portions  of  the 
lungs,  while  in  the  simple  form  they  are  more  often  posterior. 

Prognosis:  This  is  bad.  All  the  cases  die  in  a  short  time, 
except  the  few  which  go  on  to  the  chronic  condition. 

Acute  pulmonary  tuberculosis — treatment:  To  prevent  the 
disease  all  children,  and  especially  those  with  a  hereditary 
predisposition,  should  be  well  led,  well  clothed,  and  kept  most 
of  the  time  in  the  fresh  air.  I  ('  consumptives  are  in  the 
family,  all  their  sputa  must  be  carefully  destroyed  by  chemi- 
cals or  fire.     These  children  should  not  sleep  with  nor  kiss 


254  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

tubercular  people.  All  milk  and  meat  should  be  carefully 
inspected  before  use.  Tuberculous  mothers  should  not  nurse 
their  children.  All  infectious  diseases  or  pulmonary  inflam- 
mations in  these  children  should  be  most  carefully  treated 
with  this  end  in  view. 

If  the  disease  has  begun,  the  treatment  consists  in  keeping 
the  stomach  and  bowels  in  good  condition,  so  that  we  will  be 
able  to  over-nourish  the  child  ;  to  allow  an  abundance  of 
fresh  air ;  and  to  give  creosote  in  full  doses  to  tolerance. 
Special  symptoms  are  to  be  treated  as  they  arise. 

CHRONIC  PULMONARY  TUBERCULOSIS. 

Etiology :  This  form  is  seen  mostly  in  older  children,  and 
differs  very  little  from  the  same  condition  as  seen  in  adults. 
The  predisposing  and  actual  causes  are  the  same  as  in  the 
acute  variety.  A  good  many  of  the  cases  follow  an  attack 
which  began  acutely,  or  are  secondary  to  protracted  simple 
inflammations  of  the  lungs,  or  develop  gradually  from  a 
latent  tuberculosis  of  the  bronchial  glands. 

Pathology :  The  growth  of  miliary  tubercles  and  of  tuber- 
cular masses  scattered  through  the  lung,  with  the  accompany- 
ing chronic  bronchitis  or  broncho-pneumonia,  are  the  begin- 
ning lesions  of  this  disease.  The  same  tendency  to  necrosis 
of  this  new-formed  tissue,  and  subsequent  formation  of  small 
cavities  exists,  as  in  adults.  The  apex  is  not  so  regularly  the 
location  of  the  early  lesions  as  in  older  patients,  this  being 
more  often  in  the  neighborhood  of  the  bronchial  glands.  In 
different  parts  of  the  lung  are  found  bands  of  fibrous  con- 
nective tissue,  and  the  pleura  is  regularly  thickened  and 
adherent.     The  whole  lung  is  irregularly  consolidated. 

Chronic  pulmonary  tuberculosis — symptoms:  The  symptoms 
ordinarily  follow  those  of  some  previous  disease  during  its 
convalescence.  They  are  cough,  irregular  fever,  loss  of  flesh 
and  strength,  increasing  pallor,  and  general  prostration. 
Haemoptysis  and  expectoration  are  rare.  The  appetite  is  lost ; 
there  may  be  vomiting  and  diarrhoea.  The  pulse  is  rapid  and 
feeble,  and  the  respiration  is  accelerated.  As  the  disease 
progresses    sweating  is  common    and  the  temperature    may 


CHRONIC  PULMONARY  TUBERCULOSIS.  255 

take  on  a  hectic  course.  The  wasting  becomes  excessive  and 
the  strength  very  feeble.  Tubercular  diarrhoea  and  laryn- 
gitis may  appear  as  complications,  and  toward  the  end  a  gen- 
eral oedema  may  develop,  and  the  child  dies  after  many  months 
of  excessive  emaciation  and  exhaustion. 

Chronic  pulmonary  tuberculosis — physical  signs  :  The  expan- 
sion of  the  affected  chest  is  limited.  The  vocal  fremitus  is 
apt  to  be  increased.  On  percussion,  irregularly  placed  areas 
of  dulness  or  flatness  may  be  found.  On  auscultation,  exag- 
gerated voice-  and  breathing-sounds  are  found  over  these  same 
areas,  or  there  may  be  no  change  in  the  character  of  the 
breathing.  There  are  always  present,  however,  various  kinds 
of  adventitious  sounds  scattered  irregularly  over  the  lungs — 
fine  and  coarse  rales,  bubbling  and  whistling  sounds — and  if 
small  cavities  are  present,  cavernous  breathing  with  moist 
gurgles  may  be  heard. 

The  signs  are  not  nearly  so  distinctive  as  in  adults,  and  are 
much  more  difficult  to  bring  out. 

Diagnosis :  The  irregularity  in  the  physical  signs  and 
the  history  are  the  main  points  of  value  in  diagnosis.  At 
times  a  simple  chronic  pneumonia  will  give  precisely  the 
same  signs  and  symptoms,  and  differentiation  will  be  almost 
impossible.  If  possible,  a  specimen  of  the  sputum  should  be 
obtained  and  examination  made  for  the  tubercle  bacilli.  This 
is  the  only  positive  method  of  diagnosis. 

Prognosis  :  Reeoverv  is  possible  when  the  cases  are  seen 
early  and  put  under  proper  treatment.  As  more  of  the  lung 
is  involved  and  cavities  form,  and  especially  if  the  stomach 
fails,  the  prognosis  becomes  bad. 

Chronic  pulmonary  tuberculosis — treatment :  The  preventive 
treatment  should  be  followed  as  is  outlined  for  the  acute 
variety. 

For  the  treatment  of  the  disease  itself,  life  in  the  fresh  air, 
if  possible  in  a  elimatc  that  is  dry  and  high,  i-  of  most  im- 
portance. Special  attention  should  lie  paid  to  the  condition 
of  the  stomach  and  bowels,  in  order  that  the  child  may  take 
and  digesi  and  assimilate  a  large  quantity  of  nourishing  food. 
Food  rich  in  fat  should  be  taken  especially,  ami  \'<<v  tlii-  rea- 
son cream  and  cod-liver  oil  are  particularly  desirable.     Creo- 


256  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

sote  in  increasing  closes  has  a  decidedly  beneficial  effect. 
Symptoms  should  be  treated  as  they  arise,  the  cough  by 
soothing  cough-mixtures,  the  fever  by  sponging  or  antipy- 
retics, and  the  sweats  by  drugs  of  the  atropine  group.  It 
should  always  be  remembered,  however,  that  harm  is  done 
by  over-drugging  these  patients,  upsetting  their  digestion, 
more  often  than  by  giving  too  few  drugs. 


CHAPTER    X. 

DISEASES   OF   THE   GENITOURINARY  SYSTEM. 

ENURESIS. 

Definition :  By  this  is  meant  an  involuntary  emptying  of 
the  bladder  at  inopportune  times. 

Etiology  :  The  organic  causes  are  inflammations  of  the  blad- 
der or  other  parts  of  the  genital  tract,  and  diseases  of  the 
brain  or  spinal  cord.  These  cases,  due  to  organic  causes,  are 
not  the  ones  ordinarily  understood  by  enuresis. 

The  functional  causes  are  lack  of  proper  inhibitory  control 
from  the  cerebral  centres,  and  increase  of  the  reflexes  of  the 
cord.  Such  causes  are  anaemia,  malnutrition,  the  functional 
neuroses,  a  highly  acid  urine,  or  one  containing  some  abnor- 
mal constituent,  irritation  from  a  foreign  body  in  the  bladder, 
and  reflex  irritations  from  the  genital  tract,  as  phimosis,  bala- 
nitis, and  vulvitis,  or  from  the  rectum  and  anus,  as  polyps, 
worms,  and  fissure.  Children  of  a  neurotic  heredity  are 
particularly  liable  to  the  disease. 

Enuresis — symptoms  :  Involuntary  emptying  of  the  bladder 
is  the  only  symptom.  This  most  commonly  occurs  at  night 
only,  in  some  cases  by  day  only,  and  in  others  both  by  day 
and  by  night.  It  may  occur  every  night  once  or  even  more 
times,  or  only  irregularly.  The  condition  usually  lasts  from 
infancy  for  some  years — at  times  until  puberty. 

Diagnosis  :  The  point  of  diagnosis  is  to  discover,  if  possible, 
any  causative  factor  or  factors  that  may  be  present. 

Prognosis:  The  organic  cases  cannot  be  cured.  The  func- 
tional cases  eventually  outgrow  the  trouble.  In  some  (he  re- 
sponse to  treatment  is  very  satisfactory  ;  in  others,  no  means 
that  can  be  taken  seem  to  have  any  influence  over  the  con- 
dition. 

Enuresis — treatment:  Hunt  for  any  possible  cause  and  rc- 
17— J».  C.  257 


258      DISEASES  OF  THE  GENITO-URINARY  SYSTEM. 

move  it,  going  systematically  through  the  whole  list.  All 
measures  directed  to  improving  the  child's  general  health 
should  be  strictly  carried  out.  The  diet  and  the  quantity 
of  fluid  allowed  should  he  carefully  regulated.  The  child 
should  not  be  punished  for  wetting  himself,  but  on  the  con- 
trary should  be  rewarded  when  he  does  not  do  so.  He 
should  sleep  in  a  warm  room,  with  warm  coverings,  and  with 
the  foot  of  the  bed  raised  higher  than  the  head.  He  should 
empty  his  bladder  the  last  thing  before  going  to  bed,  and 
should  be  taken  up  again  before  the  parents  retire.  During 
the  daytime  he  should  be  trained  to  hold  his  urine  as  long  as 
possible. 

As  drugs,  the  most  valuable  are  belladonna,  cantharides, 
and  strychnine.  The  first  should  be  given  in  maximum  doses 
in  the  evening.  It  is  well  to  give  cantharides  at  the  same 
time  to  add  an  irritating  effect  to  the  vesical  neck,  and  hence 
tonicity  to  the  sphincter.  These  act  best  in  cases  of  neurotic, 
irritable  children.  In  children  whose  muscular  tone  is  below 
par,  strychnine,  given  regularly,  has  some  value. 

Passage  of  cold  sounds,  galvanism  to  the  neck  of  the 
bladder,  and  distention  of  the  bladder  daily  until  its  capacity 
is  increased,  may  be  tried  if  the  above  measures  fail. 

VESICAL  CALCULUS. 

Stone  in  the  bladder  occurs  with  some  frequency  in  children 
after  the  second  or  third  year  of  life.  Most  of  the  stones  are 
of  the  uric-acid  variety.  Rarer  forms  are  the  oxalate  of 
lime  or  the  phosphatic  stones.  They  vary  in  size  and  may 
be  multiple.  They  may  be  free  in  the  bladder  or  attached  to 
its  wall. 

Etiology :  The  stone  is  usually  formed  around  a  small  con- 
cretion which  has  passed  from  the  kidney  to  the  bladder. 
Excessively  concentrated  urine  from  improper  diet  or  the 
use  of  too  little  liquid,  seems  to  favor  the  causation.  Other- 
wise little  is  known. 

Foreign  bodies  passed  into  the  bladder  from  the  urethra 
are  rare  causes. 

Vesical  calculus — symptoms  :  These  are  like  the  symptoms 


DIABETES  INSIPIDUS.  259 

seen  in  adults — pain  at  the  end  of  urination,  excessive  irri- 
tability of  the  bladder,  and  sudden  stoppage  of  the  stream 
during  the  act  of  micturition.  The  urine  may  contain  mucus 
and  blood  in  small  quantities,  and  signs  of  cystitis  may  de- 
velop. Enuresis  and  rectal  tenesmus  with  a  tendency  to  pro- 
lapse are  often  seen. 

Diagnosis :  The  symptoms  are  fairly  typical,  but  the  diag- 
nosis should  always  be  confirmed  by  the  passage  of  a  searcher 
into  the  bladder. 

Prognosis :  Without  treatment  the  prognosis  is  bad,  but 
under  intelligent  surgical  care  these  cases  should  be  cured. 

Vesical  calculus — treatment :  The  stone,  after  discovery, 
should  be  removed  either  by  lithotrity  or  by  perineal  or  su- 
prapubic cystotomy.  The  latter  operation  is  most  in  favor 
during  recent  years. 

After  removal  of  the  stone,  steps  should  be  taken  to  pre- 
vent formation  of  others,  bv  attention  to  the  diet  and  mode 
of  life. 

DIABETES  INSIPIDUS. 

Definition :  This  is  also  called  polyuria,  and  is  a  neurosis 
characterized  by  the  secretion  of  large  quantities  of  pale  urine 
of  low  specific  gravity  and  containing  no  abnormal  con- 
stituents. 

Etiology:  This  disease  occurs  with  some  frequency  in 
grown  children.  It  is  usually  in  some  way  connected  with 
nervous  causes,  as  shock,  fright,  or  a  neurotic  predisposition. 
Otherwise  the  causative  factors  are  unknown. 

Pathology:  No  lesions  are  to  be  found  in  the  kidneys. 
Various  forms  of  irritation  have  been  found  over  the  floor 
of  the  fourth  ventricle. 

Diabetes  insipidus — symptoms:  Very  large  quantities  of 
urine  are  passed  per  day.  The  specific  gravity  is  low  and 
the  ingredients  normal.  The  child  is  thirsty,  loses  flesh,  and 
becomes  amemic,  and  presents  irregular  nervous  and  hysteri- 
cal symptoms.  The  disease  lasts  for  years,  with  intervals  of 
improvement. 

Diagnosis:  Frequent  urinary  analyses  must  be  made  to 
exclude  chronic  nephritis. 


2t»0      DISEASES  OF  THE  GENITO-URINARY  SYSTEM. 

Prognosis :  This  varies  a  good  deal.  Many  of  the  cases 
recover  in  time,  but  others  seem  incurable. 

Diabetes  insipidus — treatment:  Great  attention  should  be 
paid  to  all  hygienic  measures  to  put  these  children  in  the  best 
health  possible.  The  diet  should  be  nutritious  and  largely 
albuminous.  As  drugs,  ergot,  gallic  acid,  belladonna,  and 
the  mineral  acids  are  used.  The  treatment  should  be  con- 
tinued over  long  periods  of  time. 

FUNCTIONAL  ALBUMINURIA. 

Etiology :  This  condition  is  quite  a  frequent  one  in  adoles- 
cents, although  seldom  seen  in  children.  In  some  cases  it  is 
paroxysmal  in  character,  coming  at  certain  times  with  no 
special  cause  and  then  disappearing  to  return  again  later.  In 
these  cases  it  is  more  often  present  by  day  than  by  night.  In 
others  it  is  dietetic,  always  following  certain  articles  of  food, 
which  are  usually  of  a  proteid  nature.  In  others  it  is  due  to 
excessive  exercise  or  to  fatigue.  In  some  cases  no  cause  can 
be  assigned. 

Pathology  :  No  known  lesions  exist.  There  may  be  irrita- 
tion from  some  abnormal  chemical  ingredients  in  the  urine, 
or  it  may  be  simply  an  exudation  of  serum  through  the  kid- 
neys, due  to  some  vaso-motor  disturbance. 

Functional  albuminuria — symptoms  :  The  presence  of  albu- 
min in  the  urine,  without  subjective  symptoms,  is  what  we 
expect  in  this  condition.  Casts  are  regularly  absent.  Some 
of  the  subjects  are  persons  not  in  the  best  of  health. 

Diagnosis  :  This  can  be  made  usually  only  after  long  obser- 
vation of  the  patient  and  frequent  examinations  of  the  urine, 
so  as  to  exclude  actual  renal  disease. 

Prognosis :  If  the  disease  is  purely  functional,  the  prog- 
nosis is  good.  The  point  is  as  to  whether  these  children 
may  not  be  the  persons  who  in  adult  life  will  develop  ne- 
phritis. 

Functional  albuminuria — treatment :  This  consists  in  im- 
proving the  patient's  general  health,  regulating  his  diet  and 
exercise,  and  giving  iron.  Intelligent  care,  followed  for  a 
sufficient  length  of  time,  usually  effects  a  cure. 


ACUTE  EXUDATIVE  NEPHRITIS.  261 

ACUTE  DEGENERATION  OF  THE  KIDNEYS. 

Definition  :  This  is  the  simplest  form  of  what  may  be  called 
"  acute  Bright' s  disease." 

Etiology  :  It  is  seen  in  almost  all  cases  of  infectious  disease 
in  children,  being  secondary  to  all  forms  of  toxaemia — chem- 
ical or  bacterial. 

Pathology:  There  are  simply  degeneration  and  death  of  the 
renal  epithelium.  The  cells  are  swollen,  opaque,  and  contain 
fat.  Later  they  disintegrate  and  desquamate.  The  kidneys 
are  usually  a  little  swollen  and  pale. 

Acute  degeneration  of  the  kidneys — symptoms :  There  are 
no  subjective  symptoms,  although  the  presence  of  the  nephri- 
tis adds  to  the  dangers  of  the  original  disease.  The  urine  is 
diminished  in  quantity,  and  may  be  suppressed.  There  may 
be  small  quantities  of  albumin  and  a  few  casts  in  the  urine, 
but  more  often  neither  can  be  found. 

Prognosis  :  This  is  good ;  as  after  recovery  from  the  original 
disease  the  kidney  returns  completely  to  normal. 

Acute  degeneration  of  the  kidneys — treatment :  During  the 
continuance  of  the  causative  infectious  fever  the  diet  should 
be  fluid  and  largely  milk.  Otherwise  no  special  treatment  is 
needed,  except  in  case  of  suppression,  when  the  bowels  and 
skin  should  be  called  on  to  act  freely. 


ACUTE  EXUDATIVE  NEPHRITIS. 

Synonyms  :  Other  names  for  this  variety  are  parenchyma- 
tous and  desquamative  nephritis. 

Etiology  :  It  may  be  primary,  with  no  discoverable  cause  ; 
but  is  most  often  secondary  to  the  infectious  diseases,  particu- 
larly scarlatina  and  diphtheria. 

Pathology:  The  kidneys  are  large,  soft,  and  congested, 
and  their  markings  indistinct.  The  renal  epithelium  is  swol- 
len, opaque,  degenerated,  and  detached.  The  struma  is  infil- 
trated with  serum,  white  blood-cells,  and  coagulated  matter. 
The  cells  of  the  glomeruli  are  swollen  and  increased  in  num- 
ber. The  tubules  may  be  dilated.  In  places  minute  abscesses 
may  be  found. 


262      DISEASES  OF  THE  GENITO- URINARY  SYSTEM. 

Acute  exudative  nephritis — symptoms  :  The  disease  usually 
begins  acutely  with  fever,  vomiting,  and  rapid  pulse  and  res- 
piration. The  child  is  restless,  sleeps  badly,  and  complains 
of  headache.  The  bowels  are  apt  to  be  loose.  The  urine  is 
decreased  in  quantity,  and  in  severe  cases  may  be  suppressed. 
Albumin,  casts,  and  at  times  blood  are  found  in  it. 

As  the  disease  progresses  the  fever  runs  an  irregular  but 
rather  low  course.  Ancemia  develops  rather  rapidly,  and  the 
symptoms  pertaining  to  the  nervous  system  are  especially 
prominent :  restlessness,  twitchings,  and  even  convulsions 
being  regularly  present.  Other  patients  become  dull,  and 
pass  into  a  condition  of  stupor  and  coma.  Dropsy  is  not  a 
marked  symptom,  but  is  usually  present. 

Other  cases  run  a  much  less  acute  course,  with  all  the 
symptoms  milder.  The  regular  duration  of  the  disease  varies 
from  two  to  four  weeks. 

Diagnosis :  This  combination  of  symptoms  should  always 
lead  to  a  careful  examination  of  the  urine.  The  different 
forms  of  nephritis  are  often  difficult  to  differentiate,  except 
after  observation  extending  over  some  time. 

Prognosis :  In  very  young  children  this  is  a  rather  fatal 
disease;  but  on  the  whole  the  majority  of  cases  recover,  and 
the  kidneys  return  to  normal.  Some  few  go  on  to  have 
chronic  Bright's  disease. 

Acute  exudative  nephritis — treatment :  The  child  is  to  be 
kept  in  bed,  in  a  warm  room,  and  put  on  a  milk-diet.  Large 
quantities  of  water  should  be  given,  and  the  bowels  kept 
freely  open  by  the  use  of  salines  daily.  Counterirritation 
should  be  applied  to  the  lumbar  region  by  means  of  dry  cups. 
The  skin  should  be  made  to  act  freely  by  hot  packs,  or  hot- 
air  baths.  If  the  pulse  is  full  and  strong,  such  drugs  as 
nitroglycerin,  or  opium,  or  chloral  hydrate  should  be  given. 
If  the  heart  is  acting  feebly,  caffeine  is  valuable.  If  the 
cerebral  irritation  is  marked,  and  convulsions  threaten  not- 
withstanding the  above  steps,  venesection  will  act  quickly 
and  satisfactorily.  There  is  no  place  where  it  has  the  value 
it  does  in  these  conditions  of  suppression  of  urine. 

After  the  acuteness  of  the  disease  has  passed  away  great 
care  should  be  exercised  in  returning  to  the  regular  diet,  and 


ACUTE  DIFFUSE  NEPHRFTIS.  263 

in  preventing  chilling  of  the  skin.     Iron  and  tonics  will  then 
be  needed  to  cure  the  anaemia  and  build  up  the  strength. 

ACUTE  DIFFUSE  NEPHRITIS. 

This  form  of  nephritis  differs  from  the  preceding  mainly  in 
leaving  a  damaged  kidney  behind. 

Etiology :  This  condition  may  be  due  to  exposure  to  cold 
or  wet ;  but  is  most  often  secondary  to  one  of  the  infectious 
diseases,  and  particularly  to  scarlatina  or  diphtheria. 

Pathology :  All  the  changes  seen  in  the  exudative  form  are 
present,  and  in  addition  we  find  a  growth  of  new  connective 
tissue  scattered  irregularly  through  the  stroma  of  the  kidney, 
and  a  growth  of  the  glomerular  capsule  cells  such  that  they 
compress  the  tufts  of  vessels.  Both  of  these  changes  are 
permanent,  and  leave  a  kidney  damaged  by  the  replacement 
of  some  of  its  secreting  structure  by  fibrous  tissue. 

Acute  diffuse  nephritis— symptoms  :  The  disease  may  rarely 
begin  acutely  and  behave  like  the  exudative  form  ;  but  is  more 
commonly  less  active,  with  lower  fever,  progressive  anaemia, 
anorexia,  nausea  and  vomiting,  and  loss  of  flesh  and  strength. 
Dropsy  is  a  regular  symptom  of  this  variety,  and  is  quite 
marked.  Nervous  symptoms — headaches,  restlessness,  and 
delirium,  or  stupor  and  coma — are  regularly  present.  Convul- 
sions are  fairly  frequent.  The  urine  is  diminished  in  quantity, 
and  contains  albumin  and  casts,  and  at  times  blood. 

The  symptoms  last  from  two  to  four  weeks,  disappearing 
gradually  ;  but  slight  changes  in  the  urine  remain  for  a  long 
time  afterward. 

Diagnosis  :  This  must  be  made  from  the  exudative  variety. 
The  main  points  arc  the  less  acute  symptoms  and  the  pres- 
ence of  more  dropsy.  Often  time  only  will  differentiate 
them. 

Prognosis:  A  good  many  cases  die  during  the  acute  stage. 
Others  recover  except  for  a  damaged  kidney,  while  others  go 
on  to  a  chronic  nephritis. 

Acute  diffuse  nephritis — treatment:  During  the  acute  stage 
this  h  the  same  as  in  the  exudative  form. 

Afterward    the  child   should   be   kept    warmly  dressed,  and 


264      DISEASES  OF  THE  GENITO-VRINARY  SYSTEM. 

live  out  of  doors  in  a  warm  climate.  The  diet  should  be 
largely  carbohydrate,  with  milk  and  abundance  of  water. 
Iron  should  be  given  over  a  considerable  period  of  time. 
The  continued  administration  of  small  doses  of  the  bichloride 
of  mercury  seems  to  have  a  beneficial  influence  over  the 
kidney  lesion. 

CHRONIC  DIFFUSE  NEPHRITIS. 

In  young  children  forms  of  chronic  Bright's  disease  are 
rare,  but  probably  less  so  than  imagined  on  account  of  the 
frequent  neglect  in  examining  the  urine  of  children. 

Etiology  :  Most  of  the  cases  follow  the  acute  forms.  Others 
are  due  to  chronic  endocarditis,  or  tuberculosis,  or  hereditary 
syphilis. 

Pathology :  There  are  two  general  varieties,  that  with  and 
that  without  exudation. 

The  former  is  evidenced  by  a  large  whitish  kidney  with 
indistinct  markings.  The  renal  epithelium  is  swollen,  granu- 
lar, fatty,  and  degenerated.  The  capillaries  of  the  glomeruli 
are  dilated  and  the  tuft-cells  swollen.  Casts,  coagulated  mat- 
ter, and  necrotic  epithelium  are  seen  in  the  tubes  and  stroma. 

In  the  form  without  exudation,  which  is  commonly  known 
as  interstitial  or  granular  nephritis,  the  kidney  is  small  and 
rough  and  the  capsule  adherent.  The  cortex  is  thin  and 
irregular,  and  the  color  a  mottled  red.  The  same  changes  in 
the  renal  epithelium  and  in  the  glomeruli  are  present,  as  in 
the  preceding  variety ;  but  in  addition  there  is  a  diffuse 
growth  of  new  connective  tissue  in  the  stroma  ;  and  of  the  cells 
of  the  glomeruli.  In  places  the  tubules  are  considerably 
dilated. 

Chronic  diffuse  nephritis — symptoms  :  The  symptoms  develop 
slowly  and  insidiously,  whether  they  follow  preceding  acute 
attacks  or  come  on  primarily.  There  are  anaemia,  loss  of  appe- 
tite, attacks  of  vomiting  and  diarrhoea,  and  loss  of  flesh  and 
strength.  Nervous  symptoms  come  and  go,  headache,  sleep- 
lessness, restlessness,  and  paroxysmal  dyspnoea.  Dropsy  of 
the  subcutaneous  tissues  and  of  the  serous  cavities  is  regularly 
present  in  more  or  less  marked  form. 

The  urine,  in  the  variety  with  exudation,  does  not  differ 


TUMORS  OF  THE  KIDNEY.  265 

much  from  normal  in  amount,  but  contains  albumin  and  casts 
in  varying  quantities.  The  specific  gravity  is  below  normal. 
In  the  variety  without  exudation  the  urine  is  increased  in 
quantity  and  is  of  low  specific  gravity.  Albumin  and  casts 
are  present  only  in  small  quantities,  and  may  be  absent  alto- 
gether over  considerable  periods  of  time.  This  latter  variety 
is  rare  in  children. 

The  immediate  danger  in  chronic  nephritis  comes  from  the 
so-called  attacks  of  uraemia,  in  which  the  urinary  excretion  is 
diminished  and  the  nervous  symptoms  become  very  marked, 
frequently  going  on  to  severe  convulsions.  With  this  we  find 
a  laboring  heart-action  with  tense  arteries,  and  very  severe 
headaches. 

The  course  of  this  disease  is  very  chronic,  with  exacerbations 
and  remissions. 

Diagnosis  :  This  depends  on  frequent,  careful  examinations 
of  the  urine. 

Prognosis  :  This  is  bad,  as  recovery  is  virtually  impossible ; 
but  under  proper  direction  life  maybe  prolonged  comfortably 
over  a  period  of  many  years. 

Chronic  diffuse  nephritis — treatment :  The  child  should  live 
in  a  warm,  dry  climate  if  possible,  and  special  attention 
should  be  paid  to  warm  clothing  and  to  the  prevention  of 
exposure  to  changes  in  temperature.  The  diet  should  consist 
largely  of  milk  and  carbohydrates,  with  fruit  and  fresh  vege- 
tables. The  bowels  should  be  kept  open  freely.  Exercise 
should  be  taken  regularly,  but  not  to  fatigue.  The  prolonged 
use  of  iron  or  of  bichloride  of  mercury  is  of  much  value. 
If  the  dropsy  is  marked,  we  use  diaphoretics,  diuretics,  or 
cathartics,  and  if  necessary  tap  the  serous  cavities.  If  urae- 
mia threatens,  we  give  drugs  to  dilate  the  arteries;  Ave  sweat 
the  patient  by  hot  packs  or  the  hot-air  bath  ;  or,  if  necessary, 
perform  venesection.  If  convulsions  develop,  chloroform  is 
our  main  reliance.  Other  symptoms  are  to  be  treated  as  they 
arise. 

TUMORS  OF  THE  KIDNEY. 

Benign  tumors  are  rare.  Malignant  growths  are  fairly  com- 
mon in  children.     A  very  lew  are  congenital. 


266      DISEASES  OF  THE  GENITO-URINARY  SYSTEM. 

Tumors  of  the  kidney — pathology :  The  tumor  is  usually 
primary  to  the  kidney,  and  in  the  vast  majority  of  the  cases 
is  a  sarcoma  of  the  round-  or  spindle-cell  variety.  Myosar- 
coma is  often  found.  The  whole  kidney  may  be  replaced  by 
sarcomatous  tissue,  or  the  growth  may  develop  on  the  surface 
of  the  kidney.  The  tumor  may  press  on  the  ureter  or  infe- 
rior vena  cava.     Adhesions  may  form  to  neighboring  organs. 

Tumors  of  the  kidney — symptoms:  The  symptoms  are  a 
rather  fast-growing  tumor,  cachexia,  and  hematuria.  The 
tumor  usually  begins  posteriorly ;  but  soon  it  grows  to  the 
front,  and  often  becomes  very  large.  Its  surface  may  be 
smooth  or  tabulated.  Cachexia  develops  much  later  than  in 
malignant  growths  elsewhere.  Hcematuria  is  usually  present 
at  one  time  or  another,  and  often  early.  Pain  and  symptoms 
due  to  pressure  may  be  present. 

The  ordinary  duration  of  life  is  less  than  a  year  from  the 
time  the  tumor  is  discovered. 

Diagnosis :  The  above  set  of  symptoms  is  quite  character- 
istic  and    usually  enables  a  positive   diagnosis  to  be  made. 

Prognosis  is  absolutely  bad. 

Treatment  is  purely  surgical.  Enucleation  of  the  tumor 
and  the  kidney  should  be  performed  as  soon  as  the  diagnosis 
is  made. 

PYELITIS. 

Definition  :  This  term  is  used  to  describe  an  inflammation  of 
the  pelvis  of  the  kidney  and  of  the  neighboring  portion  of  the 
ureter.  If  the  kidney  is  involved  coincidently,  it  is  called  pyelo- 
nephritis.    If  pus  is  accumulated  in  the  sac,  pyo-nephrosis. 

Etiology:  This  condition  develops  from  renal  calculi,  tuber- 
culosis of  the  kidney,  abscesses  in  the  neighborhood,  exten- 
sion upward  of  inflammation  from  the  bladder;  and  as  a 
consequence  of  the  infectious  diseases,  particularly  sepsis. 

Pathology  :  It  may  be  unilateral  or  bilateral.  The  mucous 
membrane  is  inflamed,  swollen,  and  often  shows  minute  hem- 
orrhages. There  is  an  exudation  of  mucus  and  pus  from  the 
inflamed  membrane.  The  kidney  may  or  may  not  be  in- 
volved, but  is  regularly  so  in  the  older  cases.  Small  collec- 
tions of  pus  are  frequently  found  in  the  pelvis  of  the  kidney. 


RENAL   CALCULI.  267 

Pyelitis — symptoms :  In  an  acute  attack  there  is  a  sudden 
rise  of  fever,  accompanied  by  a  chill,  with  intense  pain  in  the 
back.  The  temperature  remains  high,  and  the  chill  may  or 
may  not  be  repeated.  Chills  occur  especially  in  the  tubercular 
cases  and  in  those  with  the  formation  of  an  abscess.  The 
urine  is  found  decreased  in  quantity,  acid  in  reaction,  and 
containing  pus,  a  little  albumin,  and  some  red  cells.  The 
cases  last  a  few  weeks,  the  fever  and  other  symptoms  disap- 
pearing very  gradually,  unless  an  abscess  is  formed  or  tuber- 
culosis exists. 

In  the  chronic  cases  pus  in  the  urine  is  often  the  only 
symptom,  unless  a  renal  tumor  is  formed  from  an  accumu- 
lation of  pus.  Acute  exacerbations  in  these  cases  are  fre- 
quent. 

Diagnosis:  This  depends  on  the  examination  of  the  urine. 
Pyuria,  with  an  acid  urine,  and  epithelial  cells  from  the 
pelvis  of  the  kidney,  are  usually  sufficient,  in  the  presence  of 
the  history,  to  establish  a  diagnosis.  A  search  in  the  pus  for 
tubercle  bacilli  should  be  made  in  the  prolonged  cases. 

Prognosis  :  This  is  fairly  good  in  the  primary  cases.  There 
is  danger  of  nephritis  developing,  however.  In  cases  due  to 
stone  or  tuberculosis  the  prognosis  is  less  favorable. 

Pyelitis — treatment:  The  child  should  be  kept  in  bed,  on  a 
plain  diet.  Large  quantities  of  water,  containing  lithia, 
citrate  of  potassium,  or  other  saline  diuretic,  should  be  given. 
Employ  strong  counter-irritation  over  the  loins  during  the 
acute  stage,  by  means  of  mustard  or  cups. 

The  question  of  surgical  interference  comes  up  in  the 
chronic  cases,  as  in  those  which  are  distinctly  due  to  calculi. 

RENAL  CALCULI. 

Small  calculi,  or  gravel,  are  common  in  children. 

Larger  calculi  are  found  but  rarely.  They  are  usually 
formed  of  uric  acid,  and  are  found  in  the  calyces  or  pelvis  of 
the  kidney.     The  small  ones  are  usually  bilateral. 

Renal  calculi — symptoms :  The  continual  secretion  of  the 
urine  tends  to  wash  the  calculi  through  the  ureters  into  the 
bladder.    Their  passage  is  accompanied  by  a  sharp  pain  radi- 


268      DISEASES  OF  THE   GEN1T0-UBTNARY  SYSTEM. 

ating  down  the  ureter  and  to  the  pelvis.  In  boys  retraction 
of  the  testicle  accompanies  it.  These  pains  come  on  sud- 
denly, and  cease  as  soon  as  the  stone  reaches  the  bladder. 
They  are  very  agonizing  and  sharp  in  character.  There  is 
regularly  tenderness  over  the  affected  side.  The  urine  passed 
just  after  the  attack  will  contain  a  little  blood  and  some  al- 
bumin, and  often  some  uric  acid  crystals. 

At  times  the  calculus  will  be  impacted  in  the  ureter,  with 
a  resulting  dilatation  of  the  pelvis  with  urine.  This  may 
be  infected  and  become  purulent. 

Diagnosis :  The  finding  of  the  stone  in  the  urine  is  proof 
positive  of  the  diagnosis,  the  other  symptoms  being  corrobo- 
rative. 

Prognosis  :  This  is  fairly  good.  There  is  danger,  however, 
of  the  development  of  nephritis,  or  pyo-nephrosis,  and  of  a 
subsequent  vesical  calculus. 

Renal  calculus — treatment :  The  child  should  be  put  on  a 
fluid  diet,  and  should  drink  very  large  quantities  of  water  to 
which  an  alkaline  diuretic  has  been  added. 

If  after  thorough  use  of  this  method  cure  is  not  effected, 
and  if  the  diagnosis  of  the  presence  of  a  stone  is  positive,  the 
case  should  be  put  under  surgical  care.  The  results  of  opera- 
tion are  fairly  good. 

PERINEPHRITIS. 

Definition :  This  is  an  inflammation  of  the  cellular  and 
fatty  tissue  surrounding  the  kidney.  The  inflammation  fre- 
quently goes  on  to  suppuration. 

Etiology :  It  may  be  secondary  to  disease  of  the  vertebra, 
or  to  suppuration  in  the  kidney  proper.  It  may  be  due  to 
exposure  to  cold,  or  to  local  traumatism,  or  follow  some  of 
the  infectious  diseases.     In  many  cases  no  cause  can  be  found. 

Pathology :  The  perinephritic  tissue  is  in  a  condition  of 
acute  exudative  inflammation,  in  which  there  is  often  such  an 
excessive  exudation  of  leucocytes  as  to  form  an  abscess.  This 
abscess  may  extend  backward  and  burst  externally.  It  may 
burrow  upward  or  downward,  and  point  in  most  unexpected 
places. 


PHIMOSIS.  269 

Perinephritis — symptoms :  The  disease  is  acute,  beginning 
with  a  chill,  rise  of  temperature,  and  pain  in  the  lumbar 
region.  The  pain  is  made  worse  by  moving  the  limb  of  the 
affected  side,  and  so  lameness  is  produced,  and  there  is  tender- 
ness on  pressure  over  the  kidney  region. 

The  fever  continues,  chills  may  be  repeated,  the  pain  is 
constant,  and  the  child  appears  quite  sick  and  willingly  stays 
in  bed.  Vomiting  is  a  rather  frequent  symptom.  As  the 
disease  progresses  an  indefinite  tumor  may  be  made  out  in 
the  loin,  the  skin  of  the  back  over  the  abscess  gradually 
reddens,  and  evacuation  may  take  place  through  the  skin. 
In  other  cases  the  abscess  may  burrow  and  burst  through  the 
groin,  or  into  the  bowel  or  peritoneum.  In  some  cases  reso- 
lution takes  place  without  the  formation  of  abscess. 

The  duration  of  the  disease  is  from  one  to  three  months. 

Diagnosis  :  This  is  usually  not  difficult  if  the  case  is  studied 
carefully.  It  differs  from  pyelitis  in  being  accompanied  by 
no  changes  in  the  urine;  and  from  hip-disease,  with  which  it 
is  sometimes  confounded,  by  the  slower  course  of  the  latter. 

Prognosis  :  The  patient  usually  recovers.  The  danger  lies 
in  rupture  of  the  abscess  into  the  peritoneum. 

Perinephritis — treatment :  The  patient  should  be  put  to  bed 
on  a  light  diet,  the  bowels  moved  by  fractional  doses  of 
calomel,  and  ice-bags  kept  applied  to  the  inflamed,  side  of  the 
body.  If  suppuration  is  deemed  inevitable,  hot  poultices 
should  be  used,  and  at  the  first  signs  of  the  abscess  approach- 
ing the  surface  an  incision  should  be  made  through  the  lum- 
bar region  to  evacuate  the  pus. 

PHIMOSIS. 

Definition  :  In  this  condition  the  opening  through  the  pre- 
puce is  so  contracted  that  the  glans  cannot,  or  can  only  with 
great  difficulty,  be  pushed  through  it.  It  is  a  congenital  con- 
dition which  is  very  common,  and  is  regularly  associated  with 
adhesions  between  the  prepuce  and  glans.  At  times  there  is 
enough  narrowing  actually  to  interfere  with  the  passage  of 
urine.  If  the  prepuce  is  forcibly  retracted,  there  is  found  in 
the  sulcus  about  the  corona  a  whitish  secretion  called  the 
smegma. 


270      DISEASES  OF  THE  GENITO- URINARY  SYSTEM. 

Phimosis — symptoms :  This  condition  may  be  unaccom- 
panied by  any  symptoms,  but  various  local  and  reflex  results 
of  it  are  frequently  found.  Among  these  are  attacks  of 
balanitis  from  the  impossibility  of  cleanliness  ;  hernia  or  pro- 
lapsus ani  from  straining ;  enuresis,  masturbation,  insomnia, 
night-terrors,  and  general  convulsions  from  reflex  irritation. 
Rarer  effects  are  chorea,  epilepsy,  and  gastralgia. 

Phimosis — treatment :  Where  the  prepuce  is  not  too  long, 
it  should  be  forcibly  retracted,  the  adhesions  broken  up,  any 
smegma  removed,  and  the  parts  anointed  with  a  little  vaseline 
before  the  foreskin  is  returned  to  its  proper  place.  This 
should  be  repeated  every  day  until  return  becomes  easy. 

In  case  of  long  foreskin  or  where  retraction  is  impossible 
circumcision  should  be  done. 


BALANITIS. 

Definition  :  This  is  an  inflammation  of  the  mucous  mem- 
brane covering  the  glans  and  lining  the  prepuce. 

Etiology:  Uncleanliness  from  adherent  prepuce  and  irri- 
tation or  injury  of  the  parts  from  infection,  or  masturbation, 
or  urethritis,  are  the  main  causes. 

Balanitis — symptoms  :  The  parts  are  swollen,  red,  inflamed, 
and  tender.  After  a  few  days  there  is  an  increased  secre- 
tion ;  and  then  a  rapid  amelioration  of  the  symptoms.  In 
tightly  adherent  prepuce  the  inflammation  may  be  so  intense 
as  to  cause  sloughing. 

Balanitis — treatment :  If  the  prepuce  is  adherent,  it  is  often 
necessary  to  slit  up  the  dorsal  segment  of  it,  or  to  perform 
circumcision  first.  In  any  case  the  prepuce  must  be  retracted, 
and  the  parts  kept  scrupulously  clean  with  soap  and  water. 
Afterward  a  saturated  boric  acid  solution  should  be  applied. 

VULVOVAGINITIS. 

Definition :  This  is  a  catarrhal  inflammation  of  the  vulva 
and  lower  vagina.     It  is  fairly  common  in  young  children. 

Etiology :  There  are  two  general  varieties,  the  simple  and 
the  specific  or  gonorrhoea!.     The  former  is  due  to  dirty  diapers 


VULVO-VAG INITTS.  271 

or  drawers,  or  to  wearing  none,  or  to  other  lack  of  proper 
cleanliness.  In  some  cases  it  is  due  to  pinworms,  or  to  in- 
fection from  the  rectum  from  other  causes. 

The  specific  form  is  due  to  infection  by  the  gonococcns, 
either  from  attempts  at  rape,  or  more  often  from  use  of 
towels,  rags,  and  utensils  that  have  become  infected. 

Vulvo-vaginitis — symptoms  :  There  are  itching,  burning,  and 
irritation  of  the  parts,  with  pain  on  urination.  There  is  a 
marked  thin,  or  thick,  or  creamy  discharge  present,  which 
dries  and  forms  crusts  over  the  vulva.  The  mucous  mem- 
brane is  red  and  inflamed,  and  the  skin  is  excoriated.  In  the 
most  severe  cases  there  are  mild  constitutional  symptoms  of 
fever  and  malaise. 

The  simple  cases  usually  heal  rather  readily  under  treat- 
ment ;  the  specific  variety  is  very  obstinate. 

Comj)lications  are  likely  to  arise — urethritis,  cystitis,  pelvic 
inflammations,  and  conjunctivitis. 

Diagnosis :  The  specific  form  is  distinguished  from  the 
simple  by  its  greater  severity,  and  the  discovery  of  the  gono- 
cocci  in  the  discharge. 

Vulvo-vaginitis — treatment :  Absolute  cleanliness  is  the  key- 
note of  treatment.  Dried  secretions  should  be  removed  with 
soap  and  warm  water,  and  the  parts — vulva  and  vagina — irri- 
gated twice  daily  with  weak  bichloride  or  saturated  boric  acid 
solution.  Vaseline  should  then  be  applied  to  the  skin  around 
the  vulva.  Pads  of  cotton  or  of  gauze,  damped  with  boric  acid 
solution,  should  be  worn  continuously.  In  some  cases  strong 
solutions  of  silver  nitrate  must  be  used.  Measures  should  be 
taken  to  protect  the  eyes  from  infection. 


CHAPTER   XI. 

DISEASES  OF   THE  NERVOUS  SYSTEM. 

PERIPHERAL  NEURITIS. 

Definition :  By  this  term  is  understood  an  inflammation  of 
the  peripheral  nerves.  This  may  involve  only  one  or  more 
nerves,  but  often  many  in  different  regions  of  the  body  are 
affected. 

Etiology :  Local  traumatism,  exposure  to  cold,  the  toxins 
from  the  infections  diseases,  as  diphtheria,  la  grippe,  and 
typhoid,  and  certain  chemical  poisons,  as  alcohol,  arsenic,  and 
lead,  are  all  well-recognized  causes. 

Pathology :  The  affected  nerve  shows  some  signs  of  an  exu- 
dative inflammation,  but  the  characteristic  changes  are  a  de- 
generation of  the  nerve-fibres. 

Peripheral  neuritis — symptoms  :  The  disease  develops  grad- 
ually. There  is  more  or  less  neuralgic  pain  in  the  affected 
nerves,  with  distinct  tenderness  to  pressure  over  them.  Hy- 
peresthesia, with  numbness  and  tingling,  is  frequently  pres- 
ent. The  muscles  supplied  by  the  affected  nerves  gradually 
lose  their  power,  and  eventually  become  paralyzed.  The  ex- 
tensors are  oftenest  affected,  giving  wrist-drop  and  toe-drop. 
Atrophy  is  quite  rapid  in  these  same  muscles.  The  reflexes 
are  lost.  Electrical  reactions  are  changed,  until  in  the  ex- 
treme cases  there  is  no  response  to  any  form  of  current.  In 
old  cases  contractures  and  deformities  occur. 

In  some  of  the  more  acute  cases  constitutional  symptoms 
with  fever  and  malaise  are  present  for  a  time.  The  disease 
lasts  for  one  or  two  months,  and  recovery  occurs  very  slowly. 
Where  nerves  supplying  vital  organs  are  involved  death  is  a 
frequent  result,  as  in  involvement  of  the  vagus  after  diph- 
theria. 

Diagnosis:  It  is  necessary  to  distinguish  paralysis  due  to 

272 


ACUTE  ANTERIOR  POLIOMYELITIS.  273 

cerebral  and  spinal  lesions  from  this  form.  Cerebral  lesions 
cause  no  atrophy,  and  are  usually  accompanied  by  increased 
reflexes.  Anterior  poliomyelitis  is  accompanied  by  atrophy 
and  loss  of  reflexes;  but  is  usually  confined  to  one  set  of  mus- 
cles in  one  limb,  while  neuritis  is  apt  to  be  symmetrical.  In 
poliomyelitis  there  is  no  pain  over  the  nerve-trunks. 

Neuritis  of  the  facial  nerve  is  usually  due  to  cold  or  trauma, 
or  extension  of  the  inflammation  from  the  mastoid  cells. 
Neuritis  of  the  nerves  supplying  the  forearm  extensors  is 
usually  due  to  lead ;  and  of  those  supplying  the  extensors  of 
the  feet  to  arsenic.  Neuritis  in  the  nerves  of  the  throat  or 
eyes,  and  in  the  pneumogastric,  is  ordinarily  due  to  diph- 
theria. 

Prognosis :  Recovery  is  the  rule  after  a  long,  slow  conva- 
lescence. A  few  cases  leave  a  permanent  paralysis.  If  the 
pneumogastric  is  involved,  death  is  likely  to  result. 

Peripheral  neuritis — treatment:  If  the  causative  factor  can 
be  discovered  and  removed,  this  should  be  the  first  step  in  the 
treatment.  The  child  should  be  kept  in  bed  and  as  quiet  as 
possible.  In  the  early  stages  the  main  point  is  to  relieve  the 
pain.  This  is  done  by  dry,  hot  applications,  and  by  the  use 
of  phenacetin.  In  some  cases  opium  will  be  necessary. 
Strychnine  is  to  be  given  regularly,  and  acts  as  a  good  tonic. 

After  the  acute  stage  has  passed  regeneration  is  hurried 
by  the  use  of  electricity  daily  or  on  alternate  days.  Massage 
and  general  tonics,  o£  which  iron  and  cod-liver  oil  are  the 
best,  are  valuable  adjuncts.  In  severe  dysphagia,  due  to 
paralysis  of  the  throat  after  diphtheria,  feeding  by  the  stom- 
ach-tube may  be  required.  In  involvement  of  the  pneumo- 
gastric, combinations  of  morphine  and  strychnine,  the  latter 
pushed  to  its  limit,  are  of  most  value.  Faradism  to  the 
diaphragm  may  also  be  tried. 

ACUTE  ANTERIOR  POLIOMYELITIS. 

Synonyms:  This  disease  is  very  common  in  childhood.  It 
is  also  called  infantile  paralysis  or  infantile  spinal  paralysis. 

Etiology:  The  disease  occurs  oftenest  before  the  fifth  pear 
of  life,  and  it  ha.-  been  suggested  that  the  efforts  of  learning 

18— 1>.  C. 


274  DISEASES  OF  THE  NERVOUS  SYSTEM. 

to  walk  have  an  etiological  relationship  to  it.  Trauma  and 
changes  in  temperature  are  also  ascribed  as  causes.  Some 
cases  develop  subsequently  to  the  infectious  diseases.  There 
is  some  evidence  that  the  disease  itself  may  be  of  germ 
origin. 

Pathology :  The  lesion  is  an  acute  inflammation  in  the  an- 
terior horns  of  the  gray  matter  of  the  spinal  cord.  The  cells 
in  this  area,  which  is  usually  a  limited  one,  are  destroyed  in 
the  inflammatory  process,  and  after  recovery  the  cord  in  this 
region  shrinks  in  size.  So  few  cases  die  in  the  acute  stage 
that  the  lesions  seen  are  mainly  those  due  to  the  subsequent 
atrophy  of  that  portion  of  the  cord.  The  disease  most  often 
attacks  the  cervical  or  lumbar  enlargements  of  the  cord,  and 
usually  on  one  side  only. 

Acute  anterior  poliomyelitis — symptoms  :  The  disease  regu- 
larly begins  acutely,  with  fever  of  101°  to  104°  F.,  vomiting, 
marked  prostration,  and  pain  in  the  limbs.  Many  cases  also 
have  one  or  more  general  convulsions.  These  acute  symp- 
toms, similar  to  those  of  an  infectious  disease,  last  for  a  few 
days  without  any  definite  local  signs  developing,  when  one  or 
more  of  the  limbs  are  found  to  be  paralyzed.  Gradually  the 
constitutional  symptoms  disappear,  but  the  paralysis  remains. 
The  affected  limb  is  regularly  entirely  involved  at  first,  but 
as  the  weeks  pass  by  some  of  the  muscles  regain  their  power, 
and  eventually  only  one  group,  as  for  instance  the  anterior 
tibial,  is  left  permanently  paralyzed.  In  some  cases  more 
than  one  group,  or  different  groups  in  different  limbs,  are 
permanently  affected. 

After  about  three  months  whatever  parts  were  to  recover 
have  done  so,  the  paralysis  in  the  other  groups  being  perma- 
nent. After  years  this  paralysis  may  lead  to  contractions 
and  relaxations  of  joints,  causing  bad  deformities,  the  limb 
being  decidedly  atrophied  and  feeble,  the  reflexes  gone,  and 
the  reaction  of  degeneration  to  electricity  being  present. 

Diagnosis  :  In  the  early  stages  it  may  be  mistaken  for  one 
of  the  infectious  diseases  or  for  meningitis.  A  few  days'  ob- 
servation will  settle  this  point. 

Confusion  may  exist  between  it  and  cerebral  paralysis,  or 
peripheral  neuritis.     Cerebral  paralysis  may  begin  similarly, 


TRANSVERSE  MYELITIS.  275 

but  the  paralyzed  limb  is  well  nourished,  the  reflexes  are  in- 
creased, and  its  general  condition  is  spastic  rather  than  flaccid. 
Neuritis  begins  more  gradually,  and  has  pain  along  the  af- 
fected nerves.  In  doubtful  cases  the  diagnosis  may  be  very 
difficult  until  some  length  of  time  elapses. 

Prognosis  :  As  far  as  life  is  concerned,  this  is  good.  Death 
during;  the  acute  stage  is  rare.  Until  three  months  have 
elapsed  it  is  difficult  to  tell  what  the  permanent  damage  will 
be.  So  long  as  the  reaction  of  degeneration  does  not  develop 
the  prognosis  for  recovery  in  such  muscles  is  good. 

Acute  anterior  poliomyelitis — treatment :  During  the  acute 
stage,  if  the  diagnosis  is  made,  the  child  should  be  kept  quiet 
in  bed,  and  lying  on  its  face  or  side  rather  than  its  back. 
The  diet  should  be  liquid,  and  the  bowels  emptied  by  repeated 
fractional  doses  of  calomel.  Counter-irritation  to  the  spine 
by  means  of  mustard  applications,  or  by  cups,  or  the  use  of 
continuous  cold,  is  advisable.  Mild,  antipyretics  answer  for 
drugs.     Ergot  and  bromides  are  theoretically  indicated. 

After  the  acute  stage  is  over,  and  only  a  paralyzed  limb  is 
left,  the  muscles  in  this  limb  should  be  regularly  exercised 
by  the  use  of  electricity  in  the  form  that  will  produce  con- 
tractions.    Massage  is  a  very  useful  adjunct. 

To  prevent  and  to  cure  subsequent  deformities  various 
forms  of  orthopgedic  apparatus  are   advisable. 

TRANSVERSE  MYELITIS. 

Various  forms  of  general  myelitis  are  occasionally  seen  in 
children  ;  but  this  one,  in  which  the  lesion  involves  a  com- 
plete cross-section  of  the  cord  of  greater  or  less  extent,  is  the 
only  one  of  sufficient  frequency  to  demand  separate  consider- 
ation. 

Etiology:  This  condition  is  regularly  due  to  compression 
of  the  cord  from  the  sharp  angle  formed  in  the  spine  in 
(tuberculous)  vertebral  disease,  or  from  ;i  chronic  thickening 
of  the  meninges  due  to  the  same  trouble.  Tumors  of  the 
conl,  ami  fractures  and  dislocations  of  the  spine  produce  the 
same  lesions. 

Pathology  :  The  carious  bodies  of  the  vertebrae  collapse  and 


276  DISEASES  OF  THE  NERVOUS  SYSTEM. 

produce  bends  in  the  spine.  In  addition,  the  peritoneum  and 
meninges  undergo  a  chronic  inflammatory  process,  with  thick- 
ening of  their  tissues.  The  mechanical  bending  and  the  in- 
flammatory thickening  together  compress  the  cord  and  set  up 
an  interstitial  myelitis,  with  gradual  destruction  of  the  cells 
and  fibres,  and  with  abolition  of  their  function. 

Secondary  degenerations,  ascending  and  descending,  from 
the  involved  region,  are  also  frequent.  The  nerve-roots  are 
usually  affected  coincidently. 

Transverse  myelitis — symptoms  :  The  essential  symptom  is  a 
gradually  increasing  paralysis  of  the  parts  below  the  lesion, 
which  paralysis  is  of  the  spastic  variety  and  bilateral.  The 
reflexes,  superficial  and  deep,  are  increased,  and  there  may  be 
some  anaesthesia.  In  old  cases  some  atrophy  may  follow.  If 
the  myelitis  is  low  down,  bedsores  and  bladder  and  rectal 
difficulties  are  present.  Pains  radiating  along  the  pinched 
nerves  are  an  early  and  persistent  symptom  in  many  cases. 
The  course  of  the  disease  is  slow  and  chronic. 

Diagnosis :  With  a  careful  examination  of  the  spine  as  to 
its  flexibility  and  deformity,  the  diagnosis  of  this  disease  is 
easy. 

Prognosis  :  If  the  case  is  diagnosed  early,  and  if  under 
proper  treatment  of  the  spine  the  vertebral  disease  can  be 
stopped,  the  cord  will  often  return  to  normal.  In  the  long- 
standing cases  the  prognosis  is  not  so  good,  and  many  remain 
permanently  paralyzed. 

Transverse  myelitis — treatment :  This  is  almost  entirely 
that  of  the  vertebral  disease  causing  the  myelitis.  The  child 
should  be  put  at  rest  on  its  back,  and  kept  on  a  highly  nour- 
ishing diet.  Extension  of  some  sort  should  be  applied  to  the 
spine.  Special  efforts  should  be  made  to  prevent  the  forma- 
tion of  bedsores,  and  the  bladder  must  be  watched.  Iodide 
of  potassium  may  be  given  internally  with  possible  benefit. 

FRIEDREICH'S  ATAXIA. 

Synonym :  This  disease  of  the  spinal  cord  is  also  called 
hereditary  ataxia. 

Etiology :  It  is  distinctly  a  family  disease,  with  often  more 


PROGRESSIVE  MUSCULAR  ATROPHY.  277 

than  one  child  in  the  same  family  affected,  and  with  an  hered- 
itary history.  Neurotic  and  alcoholic  families  are  most  often 
affected. 

Pathology :  The  lesion  is  a  sclerosis  of  the  posterior  and 
lateral  columns,  and  of  the  crossed  pyramidal  and  direct  cere- 
bellar tracts  of  the  cord. 

Friedreich's  ataxia — symptoms  :  There  is  an  ataxic  gait  de- 
veloping very  early  in  life,  and  later  on  ataxia  of  the  upper 
extremities.  The  motions,  however,  are  stiffer  and  more 
rigid  than  those  of  locomotor  ataxia.  All  movements  are  ac- 
companied by  a  very  coarse  tremor.  Actual  paralysis  is  rare. 
Sensation  is  only  slightly  impaired.  The  reflexes  are  usually 
lost,  or  at  any  rate  diminished.  Bladder,  rectal,  and  trophic 
symptoms  occasionally  occur.  Contractures  and  deformities 
are  frequent  in  the  old  cases. 

The  disease  progresses  slowly  upward,  and  finally  the 
medulla  is  involved,  by  which  time  the  child  becomes  help- 
less. 

Diagnosis :  The  two  diseases  most  likely  to  be  confused  are 
locomotor  ataxia  and  multiple  sclerosis.  Both  are  diseases 
of  adult  life,  and  both  have  many  characteristic  signs  of  dif- 
ference from  Friedreich's  disease. 

Prognosis  :  This  is  distinctly  bad,  although  life  is  prolonged 
over  many  years,  but  the  stage  of  complete  helplessness  surely 
approaches. 

Treatment :  Care  for  the  general  health  is  all  that  can  be 
done. 

PROGRESSIVE  MUSCULAR  ATROPHY. 

Definition :  By  this  condition  is  understood  a  slowly  pro- 
gressing atrophy  of  certain  muscles  in  the  body  from  disease 
of  their  "trophic  centre"  in  the  spinal  cord.  The  causes  are 
unknown. 

Pathology  :  The  ganglion-cells  in  the  anterior  horns  of  the 
spinal  cord  in  some  cases  have  been  found  atrophied. 

Progressive  muscular  atrophy — symptoms  :  The  disease  begins 
slowly, and  with  no  subjective  symptoms  save  ;i  gradual  wast- 
ing and  enfeeblement  of  certain  muscles.     It  begins  oi'tcnest 


278  DISEASES  OF  THE  NERVOUS  SYSTEM. 

in  the  muscles  of  the  ball  of  the  thumb,  or  in  those  of  the 
little  finger.  It  involves  the  interossei,  and  often  later  the 
deltoid.  In  other  cases  the  anterior  tibial  or  peroneal  groups 
are  affected.  The  extreme  wasting  is  accompanied  by  pro- 
portionate weakness  and  by  persistent  fibrillary  contractions. 
The  electrical  reactions  are  unchanged  in  kind,  but  are  very 
feeble.     The  course  of  the  disease  is  slow  and  chronic. 

Diagnosis  :  This  is  rather  easy,  as  no  other  disease  simu- 
lates it. 

Prognosis  :  This  is  bad.  The  disease  is  incurable,  but  is 
consistent  with  a  fairly  long  life. 

Treatment :  General  tonic  treatment,  with  especial  atten- 
tion to  the  nutrition  is  of  most  importance. 

PSEUDOHYPERTROPHIC  MUSCULAR  PARALYSIS. 

Synonym:  This  disease  is  also  called  muscular  dystrophy, 
and  is  quite  well  recognized. 

Etiology :  It  is  a  disease  of  early  childhood,  and  shows  a 
distinct  tendency  to  run  in  families.  The  parents  are  apt  to 
be  neurotic. 

Pathology  :  There  is  at  first  a  true  hypertrophy  of  the  mus- 
cular fibres,  but  these  soon  undergo  a  fatty  and  then  a  fibrous 
degeneration,  until  finally  all  the  muscle-fibres  are  replaced 
by  connective  tissue.  The  muscles  on  section  appear  yellow- 
ish.    There  are  no  lesions  in  the  nervous  system. 

Pseudo-hypertrophic  muscular  paralysis — symptoms  :  The  be- 
ginning of  the  disease  is  very  gradual  and  difficult  to  date. 
A  gradually  progressive  weakness  in  the  legs  is  first  noticed. 
The  child  is  uncertain  on  its  feet,  and  has  great  difficulty  in 
climbing  steps,  or  in  rising  from  a  sitting  posture.  In  rising 
upright  from  the  floor  the  child  goes  through  a  characteristic 
series  of  motions  which  were  first  described  by  Gowers.  He 
first  rolls  over  on  his  face,  then  raises  himself  on  all  fours, 
and  then  bringing  his  hands  to  his  feet  uses  them  in  climbing 
up  his  legs  and  thighs,  thus  lifting  up  the  weight  of  his  body. 
Similar  weakness  develops  in  other  muscles — in  the  loins, 
producing  a  marked  lordosis  ;  in  the  shoulder  and  neck,  allow- 
ing the  head  to  drop  forward.  These  also  produce  a  very 
protuberant  abdomen. 


ACUTE  MENINGITIS.  279 

Succeeding  this  weakness  is  a  symmetrical  increase  in  bulk 
of  the  affected  muscles,  evident  especially  in  the  calves,  glu- 
tei, deltoids,  and  infraspinati.  As  the  disease  progresses  this 
hypertrophy  is  succeeded  by  a  gradually  increasing  atrophy, 
until  in  the  end  all  the  affected  muscles  are  wasted  and  flabby. 

The  gait  is  swaggering,  somewhat  similar  to  the  rolling  gait 
of  a  sailor.  There  are  no  subjective  symptoms,  and  no  blad- 
der or  rectal  trouble.  The  reflexes  are  diminished  or  lost, 
and  the  electrical  reactions  are  decreased. 

The  course  of  the  disease  is  gradually  progressive  to  the 
stage  of  complete  helplessness. 

There  are  three  recognized  types  of  the  disease — that  involv- 
ing the  legs  mainly ;  that  involving  the  shoulder-girdle,  or 
Erb's  type ;  and  that  involving  the  face  and  shoulder-girdle, 
or  the  Landouzy-Dejerine  type. 

Diagnosis  :  There  is  no  other  disease  with  which  this  may 
be  easily  confounded,  if  a  careful  history  is  taken  and  ex- 
amination is  made. 

Prognosis  :  Recovery  is  impossible.  Death  is  frequently 
due  to  intercurrent  disease. 

Treatment :  General  constitutional  treatment,  with  the  use 
of  strychnine,  is  all  that  can  be  done  for  these  cases. 

ACUTE  MENINGITIS. 

Acute  meningitis,  which  is  often  called  brain  fever,  may  oc- 
cur sporadically  without  known  cause  ;  is  often  secondary  to 
inflammations  about  the  head;  and  at  times  appears  epidemi- 
catty,  when  it  is  called  epidemic  cerebrospinal  meningitis.  In 
these  latter  cases  the  membranes  of  the  spinal  cord  are  also 
regularly  involved  ;  in  the  others,  they  may  or  may  not  be. 

Etiology:  Injuries  to  the  head,  sunstroke,  otitis,  ethmoi- 
ditis,  and  other  inflammations  about  the  head  are  apt  to  cause 
meningitis. 

In  the  sporadic  and  epidemic  eases  the  cause  is  probably 
the  action  of  some  form  of  coccus  in  the  presence  of  bad  air 
and  bad  hygienic  surroundings.  The  pneumococcus  is  most 
frequently  found.  Other  cases  complicate  the  various  infec- 
tion- diseases. 


280  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Pathology :  The  pia  mater  of  the  brain  and  of  the  cord  is 
swollen  and  infiltrated  with  varying  amounts  of  serum,  fibrin, 
and  pus.  A  distinct  layer  of  these  is  usually  found  in  the 
sulci  and  often  over  the  convolutions.  The  ventricles  are 
moderately  dilated  with  purulent  serum.  The  convolutions 
of  the  brain  are  somewhat  flattened  and  their  surface  hyper- 
semic. 

Acute  meningitis — symptoms :  The  disease  usually  begins 
rather  abruptly  with  a  rise  of  temperature  ;  at  times  a  chill 
and  intense  headache.  These  are  followed  by  vomiting  of  the 
cerebral  type — that  is,  without  nausea  or  reference  to  food — 
hyperesthesia  all  over  the  body,  photophobia,  and  general  pains. 
Convulsions  are  quite  frequent  in  children. 

The  fever  runs  an  irregular  course,  tenderness  and  con- 
traction of  the  muscles  of  the  neck  develop,  and  the  headache 
becomes  extreme.  Restlessness,  sleeplessness,  and  wild  deli- 
rium gradually  succeed  one  another.  Later  stupor  and  coma 
replace  the  active  brain-symptoms.  The  intelligence  is  soon 
lost,  and  muscular  contractions,  with  inequality  of  the  pupils 
and  various  forms  of  strabismus,  are  seen.  The  bowels  are 
usually  constipated  and  the  abdomen  retracted.  In  the  epi- 
demic cases  erythematous  and  petechial  eruptions  develop. 
The  pulse  at  first  is  apt  to  be  somewhat  slow,  but  later 
becomes  rapid  and  irregular. 

The  cases  regularly  progress  from  bad  to  worse,  and  die  in 
the  course  of  one  to  three  weeks.  Some  few  recover  with  a 
gradual  disappearance  of  the  symptoms  and  probable  absorp- 
tion of  the  exudate.  In  the  cases  which  recover,  a  chronic 
thickening  of  the  pia  is  frequently  left,  with  a  later  develop- 
ment of  hydrocephalus. 

Many  of  the  cases  run  a  much  more  subacute  course  than 
the  above,  even  beginning  more  slowly. 

Diagnosis :  In  young  children  so  many  diseases  have  such 
marked  cerebral  symptoms  suggesting  meningitis  that  in  the 
early  stages  we  may  frequently  be  in  doubt  over  the  diag- 
nosis. As  the  disease  progresses,  however,  the  diagnosis 
becomes  more  positive. 

The  tubercular  variety  is  differentiated  by  its  slower  course, 
and  by  the  family  and  personal  history.     If  a  local  cause 


TUBERCULAR  MENINGITIS.  281 

can  be  found  for  the  meningitis,  this  also  assists  the  diag- 
nosis. 

Prognosis  :  The  mortality-rate  is  very  high  ;  but  some  cases 
do  recover  permanently  and  completely  ;  in  others  various 
defects  of  the  nervous  system  are  left,  as  deafness,  blindness, 
paralysis,  and  epilepsy  ;  in  others  hydrocephalus  subsequently 
develops. 

Acute  meningitis — treatment :  The  child  should  be  put  to 
bed,  and  kept  on  a  fluid  diet,  in  a  quiet,  darkened  room.  The 
hair  should  be  cut  short,  and  continuous  cold  applied  to  the 
head  by  a  cold  coil  or  by  ice-bags.  Counterirritation  to  the 
nape  of  the  neck  by  repeated  applications  of  iodine,  or  by  a 
blister,  may  be  used.  The  bowels  should  be  kept  freely  open 
by  the  use  of  saline  laxatives. 

Internally  the  bromides,  ergot,  and  iodide  of  potassium  are 
indicated  ;  the  former  to  quiet  the  patient,  the  latter  to  relieve 
the  cerebral  congestion.  If  pain  is  severe,  opium  must  be 
used.  As  the  disease  progresses  alcoholic  stimulation  becomes 
necessary.  Attention  must  be  paid  to  the  bladder  to  prevent 
retention.  Restraint  is  often  needed  in  the  wild  delirium. 
The  sequela?  are  to  be  treated  on  general  principles. 


TUBERCULAR  MENINGITIS. 

Synonym :  This  is  also  called  basilar  meningitis,  and  is 
quite  a  common  disease  of  childhood. 

Etiology :  It  is  due  to  infection  of  the  meninges  by  the 
tubercle  bacillus.  It  is  most  apt  to  occur  in  children  of  a 
tuberculous  heredity,  or  in  those  who  have  tuberculosis  else- 
where in  the  body,  as  in  the  glands,  the  bones,  or  the  lungs. 
It  may  develop  a  long  time  after  the  cure  of  glandular  or 
bone-disease. 

Pathology:  There  are  miliary  tubercles,  and  inflammatory 
exudate  of  serum,  fibrin,  and  pus  in  the  meshes  of  the  pia 
mate!'.  They  may  be  found  anywhere  in  the  brain,  but  are 
ino-i  frequenl  over  the  base.  The  ventricles  are  moderately 
dilated  with  serum,  the  ependyma  contains  small  tubercles, 
and   the  surface  of  the   brain    is   flattened.     Tubercle   bacilli 


282  DISEASES  OF  THE  NERVOUS  SYSTEM. 

are  found  in  moderate  numbers.  Tubercular  lesions  else- 
where are  apt  to  be  found. 

Tubercular  meningitis — symptoms :  In  most  of  the  cases 
there  is  a  prodromic  period  lasting  for  a  few  days  or  weeks. 
The  child  during  this  time  loses  flesh  and  strength,  and  is  less 
inclined  to  play.  He  is  moody  and  irritable,  sleeps  badly, 
and  may  have  a  little  evening  fever  with  headache  and  a 
coated  tongue.  Sudden  attacks  of  vomiting  without  apparent 
cause  are  rather  characteristic  of  this  stage.  These  symptoms 
vary  a  good  deal,  being  more  or  less  marked  in  the  same  case 
at  different  times. 

Gradually  these  indefinite  symptoms  change  into  undoubted 
evidences  of  cerebral  disease.  There  are  now  present  irregu- 
lar fever,  intense  headache,  often  convulsions,  or  alternating 
conditions  of  stupor  and  delirium.  The  child  is  restless,  and 
sleeps  badly,  often  crying  out  suddenly  in  his  sleep.  The 
bowels  are  constipated,  and  attacks  of  vomiting  are  fre- 
quent. 

Photophobia,  general  hyperesthesia,  rigidity  of  different 
muscles,  and  transitory  or  permanent  paralyses  all  develop. 
The  pupils  are  dilated,  or  contracted,  or  unequal.  There  are 
stiffness  of  the  neck,  with  some  retraction,  and  at  times  opis- 
thotonos. The  pulse  is  slow  and  irregular ;  the  respiration 
shallow,  and  also  irregular.  There  may  be  retention  of 
urine. 

As  the  disease  progresses  the  delirious  and  irritative  symp- 
toms gradually  give  place  to  stupor  and  coma  and  loss  of  all 
subjective  sensation.  The  tongue  and  lips  become  dry  and 
covered  with  sordes,  and  all  intelligence  and  volition  are 
finally  destroyed.  Toward  the  end  there  is  inability  to  take 
food.  The  child  dies  in  convulsions,  or  more  often  ex- 
hausted in  coma.     The  temperature  rises  at  the  end. 

The  disease  lasts  from  a  week  to  a  month,  and  almost  in- 
variably shows  periods  of  distinct  improvement,  with  amelio- 
ration of  all  the  symptoms. 

Diagnosis :  In  the  prodromal  stages  the  diagnosis  is  very 
difficult,  and  is  seldom  made.  As  the  real  meningitic  symp- 
toms develop,  the  disease  becomes  more  definite,  and  a  prob- 
able diagnosis  is  fairly  easy.     In  certain  cases,  however,  it  is 


HYDR  OCEPHAL  US.  283 

almost  impossible  positively  to  differentiate  the  simple  and 
tubercular  forms. 

From  the  cerebral  types  of  non-meningitic  diseases,  after  a 
few  days'  observation,  the  diagnosis  is  usually  easily  made. 

Prognosis  :  Probably  the  disease  is  universally  fatal.  In 
the  few  cases  of  reported  recovery  there  may  have  been  an 
error  in  diagnosis,  the  condition  having  been  the  simple 
form. 

Tubercular  meningitis — treatment :  This  is  precisely  the 
same  as  for  simple  meningitis,  and  should  be  carried  out  with 
the  possibility  of  an  error  in  diagnosis  having  been  made. 

HYDROCEPHALUS. 

This  condition,  called  water  on  the  brain,  is  of  two  varieties  : 
external  hydrocephalus,  in  which  the  exuded  serum  lies  be- 
tween the  dura  mater  and  pia  ;  and  internal  hydrocephalus,  in 
which  the  serum  fills  and  distends  the  ventricles.  The  former 
condition  is  very  rare.  The  latter,  internal  hydrocephalus,  is 
the  ordinary  clinical  form. 

Etiology  :  Most  of  the  cases  begin  during  intra-uterine  life, 
and  possibly  congenital  syphilis  may  be  an  etiological  factor. 
More  than  one  child  in  the  same  family  may  be  affected.  In 
some  cases  different  causes  are  found  which  press  on  the  open- 
ing to  the  fourth  ventricle  and  cause  a  mechanical  obstruction 
to  the  outlet  of  the  ventricular  fluid.  Such  cases  are  tumors 
of  the  brain,  or  chronic  thickening  of  the  meninges.  In  most 
cases  there  is  no  satisfactory  cause  found. 

Pathology  :  The  ventricles  are  dilated,  at  times  enormously, 
with  thin  scrum  having  the  characteristics  of  cerebro-spinal 
fluid.  The  fluid  may  vary  in  quantity  from  a  few  ounces  to 
over  a  quart.  The  brain-matter  is  markedly  thinned,  under- 
going pressure-absorption.  The  skull-bones  are  widely 
separated  at  the  sutures  and  the  fontanelles  much  enlarged. 
The  ependvma  may  be  normal  or  be  somewhat  thickened. 
Spina  bifida  is  a  rather  frequent  complication. 

Hydrocephalus — symptoms:  In  sonic  eases  the  hydrocepha- 
lus is  so  developed  a1  birth  as  to  be  a  serious  obstacle  to  de- 
livery, at  times  requiring  puncture. 


284  DISEASES  OF  THE  NERVOUS  SYSTEM. 

In  other  cases  the  symptoms  develop  soon  after  birth.  The 
head  is  symmetrically  enlarged,  and  increases  in  size  often  to 
extreme  dimensions.  The  forehead  overhangs  the  eyes  and 
the  face  appears  very  small.  The  upper  lid  hangs  so  that  the 
sclerotic  shows  between  it  and  the  iris.  The  sutures  and 
fontanel! es  are  wide  open,  and  bulge  and  pulsate.  Fluctua- 
tion may  be  obtained.  The  infant  has  difficulty  in  support- 
ing its  head,  and  its  whole  muscular  system  is  flabby  and 
feeble. 

In  the  severe  cases  the  intelligence  is  more  or  less  inter- 
fered with.  Strabismus,  changes  in  the  pupil,  nystagmus, 
blindness,  deafness,  and  various  forms  of  paralysis  are  pres- 
ent. Convulsions  often  occur.  In  the  milder  cases  nothing 
except  the  enlarged  head  is  to  be  noted. 

In  some  cases  the  exudation  of  fluid  takes  place  after  ossi- 
fication of  the  cranial  bones  is  accomplished,  and  then  no  en- 
largement of  the  head  follows. 

The  course  of  the  disease  is  slowly  or  rapidly  progressive, 
and  death  regularly  takes  place  before  the  development  of 
puberty. 

Diagnosis :  The  only  disease  likely  to  cause  confusion  is 
rachitis.  In  this  the  other  signs  of  rickets  are  of  assistance, 
and  the  head  does  not  increase  in  size  so  fast,  nor  do  the  sut- 
ures or  fontanelles  gape  so  widely. 

Prognosis :  A  few  cases  recover,  but  usually  with  a  some- 
what impaired  intelligence.  The  large  majority,  however, 
are  incurable,  and  continue  to  grow  worse. 

Hydrocephalus — treatment :  There  is  nothing  satisfactory  to 
do.  Attention  to  the  general  health  should  be  strict.  Mer- 
curial inunctions  may  be  tried.  Surgical  measures,  such  as 
aspiration  or  incision,  are  not  satisfactory. 

CEREBRAL  ABSCESS. 

Notwithstanding  the  frequency  in  children  of  the  main 
causes  of  abscess  of  the  brain,  it  is  in  them  a  comparatively 
rare  disease. 

Etiology :  Suppurative  otitis,  with  or  without  involvement 
of  the  mastoid  cells,  and  traumatism  to  the  head  are  the  com- 


CEREBRAL  ABSCESS.  285 

monest  causes  of  this  disease.  General  sepsis  and  various 
inflammations  of  the  scalp  cause  some  cases.  In  a  great 
many  no  cause  is  discoverable. 

Pathology  :  The  abscess  is  usually  single,  varies  in  size,  and 
may  be  situated  almost  anywhere  in  the  brain,  but  is  most 
common  in  the  temporo-sphenoidal  lobe  or  the  cerebellum. 
There  may  be  an  encapsulated  collection  of  pus,  or  only  an 
irregular  cavity  containing  a  greenish  pus  with  broken-down 
brain-tissue  in  it,  and  surrounded  by  inflamed  brain-tissue. 

The  abscess  may  rupture  into  the  ventricles,  or  set  up  a 
meningitis,  or  cause  a  thrombosis  of  the  lateral  sinus. 

Cerebral  abscess — symptoms:  There  are  usually  described 
three  periods  in  abscess  of  the  brain — an  initial,  a  latent, 
and  the  terminal  period. 

The  initial  symptoms  may  be  mild  or  severe,  and  resemble 
those  of  acute  meningitis,  being  fever,  prostration,  headache, 
general  convulsions,  vomiting,  and  delirium  or  stupor.  The 
headache  is  apt  to  be  localized  to  the  affected  area.  After  a 
variable  time  the  symptoms  gradually  subside  and  the  latent 
stage  begins. 

During  the  latent  period,  which  may  be  short  or  long,  all 
the  symptoms  may  disappear,  or  only  the  headache  remain. 
If  any  local  symptoms  have  developed,  they  also  persist. 

After  a  variable  time  the  terminal  stage  begins  rapidly  or 
gradually,  the  fever,  headache,  vomiting,  optic  neuritis,  gen- 
eral convulsions,  and  delirium  or  stupor  return.  Various 
forms  of  paralysis  and  other  local  symptoms  may  now  be 
present,  and  all  the  symptoms  go  from  bad  to  worse. 

The  first  stage  marks  the  development  of  the  abscess,  and 
death  may  take  place  during  this.  The  latent  period  means 
the  enrapsulation  of  the  abscess.  The  final  stage  means  its 
rupture  into  the  ventricles,  or  its  spread  to  fresh  portions  of 
the  brain,  or  the  development  of  a  complicating  meningitis. 
Dentli  dikes  place  from  convulsions  or  from  exhaustion  in 
coma. 

The  disease  m:i v  last  for  a  few  weeks  only,  or,  with  a  long 
latent  period,  may  he  prolonged  over  many  months. 

Diagnosis:  Tumors  of  the  brain  are  distinguished  by  the 
lack  of  any  signs  of  inflammation.     From  acute  meningitis 


286  DISEASES   OF  THE  NERVOUS  SYSTEM. 

the  diagnosis  is  intensely  difficult.  Abscess  is  a  slower  dis- 
ease ;  and,  as  a  rule,  shows  more  of  the  local  and  less  of  the 
general  cerebral  symptoms  than  meningitis. 

Prognosis  :  Without  proper  treatment  all  the  cases  die.  A 
few  are  saved  by  surgical  interference. 

Cerebral  abscess — treatment :  During  the  beginning  stage  it 
is  that  of  acute  meningitis — cold  to  the  head,  free  purgation, 
and  the  use  of  bromides.  As  soon  as  the  diagnosis  of  abscess 
can  be  made  and  its  situation  localized,  it  should  be  treated 
surgically. 

CEREBRAL  TUMORS. 

Tumors  of  the  brain  of  different  kinds  are  fairly  common  in 
children. 

Etiology:  No  definite  cause  is  known  for  any  of  them. 
Trauma  is  often  assigned.  Tubercular,  sarcomatous,  and  car- 
cinomatous tumors  are  frequently  secondary  to  similar  growths 
elsewhere  in  the  body. 

Pathology :  The  commonest  varieties  are  the  tubercular 
tumor,  the  glioma,  the  sarcoma,  and  the  cyst.  Carcinoma, 
gumma,  and  mixed  growths  are  occasionally  found. 

Tubercular  tumors  are  often  multiple,  and  are  located  most 
often  in  the  substance  of  the  cerebellum  or  cerebrum. 

The  gliomata  resemble  the  structure  of  neuroglia,  are 
usually  single,  and  also  found  most  often  in  the  cerebellum. 

Sarcomata  may  originate  in  the  brain-tissue,  the  meninges, 
or  the  bones  of  the  skull. 

Cysts  are  found  anywhere  in  the  brain  ;  they  may  be  para- 
sitic or  degenerative. 

Cerebral  tumor — symptoms  :  These  are  best  considered  under 
two  heads — the  general  symptoms,  which  are  common  to  all 
intracranial  growths  ;  and  the  local  symptoms,  which  are  due 
to  the  situation  of  the  tumor. 

Under  the  general  symptoms  the  first  in  importance  is 
headache,  which  is  regularly  excessive  and  constant.  It  may 
be  localized  to  one  part  of  the  head  or  be  general.  Repeated 
vomiting  without  cause  and  unaccompanied  by  nausea  is 
quite  a  frequent  symptom  of  brain  tumor.  Vertigo,  either 
constant  or  paroxysmal,  is  often  present.     Optic  neuritis,  with 


CEREBRAL   TUMORS.  287 

more  or  less  interference  with  vision,  is  an  early  symptom. 
General  convulsions  occur  early,  and  are  repeated  as  the 
tumor  grows.  Mental  changes — irritability,  loss  of  memory, 
and  emotional  excitement — are  to  be  expected.  Insomnia 
begins  early;  later,  delirium  may  be  present;  and  toward  the 
end  we  find  stupor  and  coma.  The  disease  may  last  for  many 
years  before  death. 

The  local  symptoms  depend  on  where  the  tumor  grows.  In 
the  frontal  lobes,  the  emotional  and  intellectual  functions  are 
especially  involved,  but  these  local  signs  are  vague.  In  the 
third  left  frontal  there  is  motor  aphasia. 

In  the  motor  area — that  is,  around  the  fissure  of  Rolando — 
there  are  early  seen  convulsive  twitchings,  or  spasms,  of  the 
leg,  arm,  or  face  of  the  opposite  side,  according  to  the  region 
involved.  Later  there  may  develop  complete  paralysis  of 
the  same.  This  is  the  so-called  Jacksonian  epilepsy,  and  it 
is  important  to  notice  where  the  spasm  starts  and  how  it 
spreads,  as  this  enables  us  to  localize  the  site  of  the  tumor 
more  accurately.  In  the  parietal  lobes  there  may  be  some 
indefinite  sensory  symptoms  on  the  opposite  side  of  the  body. 
In  the  occipital  lobe  there  is  developed  a  homonymous  hemi- 
anopsia. In  the  temporo-sphenoidal  lobe  there  is  sensory 
aphasia  :  the  patient  can  speak,  but  cannot  understand  what 
is  spoken.  On  the  base,  in  the  anterior  fossa  we  have  inter- 
ference with  smell.  In  the  middle  fossa  there  is  atrophy  of 
the  optic  nerves,  or  interference  with  the  function  of  any  of 
the  first  six  pair.  In  the  posterior  fossa  there  will  be  inter- 
ference with  the  function  of  one  or  more  of  the  last  six  pair 
of  cranial  nerves.  In  the  cerebellum  there  is  produced  cere- 
bellar ataxia.  In  the  substance  of  the  cerebrum,  and  in  the 
cms  there  are  interference  with  the  functions  of  the  motor 
tract  and  hemiplegia  of  the  opposite  side. 

Diagnosis:  Tumor  must  be  diagnosed  from  abscess  by  the 
presence  of  fever  and  the  absence  of  optic  neuritis  in  the 
latter  condition.  From  tubercular  meningitis  of  .-low  type 
the  local  symptoms  of  tumor  arc  of  main  value  in  diagnosis. 

It  is  also  necessary  to  locate,  if  possible,  the  site  of  the 
tumor,  and  to  decide  its  variety.  The  focal  symptoms  decide 
the   former  point,  and   the   latter  is   helped    by  the   presence 


288  DISEASES  OF  THE  NERVOUS  SYSTEM. 

of  tuberculosis  or  sarcoma  elsewhere,  or  by  a  history  of 
syphilis. 

Prognosis  :  It  is  a  fatal  disease.  The  symptoms  progress 
steadily  till  death.  If  the  tumor  is  a  gumma,  which  is  very 
rare  in  children,  the  prognosis  is  better. 

Cerebral  tumor — treatment :  If  syphilis  is  suspected  espe- 
cially, but  under  any  circumstances  in  every  case,  give  mer- 
cury and  iodide  of  potassium  a  thorough  trial.  Otherwise 
surgery  is  our  only  recourse,  and  even  with  successful  local- 
ization of  the  tumor  the  surgical  results  are  not  brilliant. 
Pain  will  require  opium. 


INFANTILE  CEREBRAL  PALSIES. 

Classification  :  Clinically  there  are  three  general  classes  of 
patients  to  be  described  under  this  head  :  those  suffering  from 
hemiplegia,  or  paralysis  of  one  side  of  the  body ;  those  suf- 
fering from  diplegia,  or  paralysis  of  both  sides  ;  and  those 
suffering  from  paraplegia,  or  paralysis  of  both  lower  limbs. 

Etiology  and  pathology:  1.  Some  of  the  cases  are  due  to 
intra-uterine  disease  of  the  brain,  which  may  be  a  congenital 
defect  or  a  hemorrhage.  Porencephalus  and  cysts  are  some- 
times found.  In  others  there  is  an  arrested  development  of 
the  cortical  cells. 

2.  More  often  the  case  results  from  some  trauma  inflicted 
on  the  brain  during  parturition.  The  lesion  is  regularly  a 
meningeal  hemorrhage,  which  is  more  often  due  to  prolonged 
tedious  labor  than  to  the  use  of  forceps.  Asphyxia  at  birth 
is  usually  found  in  these  cases.  Secondary  changes  in  the 
brain  follow  the  hemorrhage,  as  a  diffuse  meningo-encepha- 
litis  with  atrophy  and  sclerosis  of  the  cortex.  Cysts  are  found 
in  some  cases.  Secondary  degenerations  of  the  motor  tract 
in  the  internal  capsule  and  cord  regularly  follow  in  the  older 
cases. 

3.  Other  cases  develop  after  birth,  and  may  follow  an 
injury  to  the  head,  or  be  subsequent  to  one  of  the  infectious 
diseases.  Severe  whooping-cough  is  often  assigned  as  a 
cause.  General  convulsions  often  leave  behind  some  form  of 
paralysis.     There  is  found  hemorrhage,  thrombosis,  or  embo- 


INFANTILE  CEREBRAL  PALSIES.  289 

lism  in  the  brain.  Subsequent  meningoencephalitis,  with 
atrophy  and  sclerosis,  and  descending  degenerations  in  the 
motor  tract  are  found. 

Infantile  cerebral  palsy — symptoms  :  The  symptoms  are  a 
greater  or  less  degree  of  spastic  paralysis  in  different  muscu- 
lar groups  of  the  body.  The  distribution  may  be  to  one  side, 
hemiplegia  ;  to  two  sides,  diplegia ;  or  to  the  lower  extremi- 
ties, paraplegia. 

The  child  is  usually  brought  to  the  physician  with  the  story 
that  it  cannot  walk.  Convulsions  of  an  epileptic  nature  are 
fairly  frequent.  The  child  remains  small  and  poorly  de- 
veloped. The  affected  limbs  are  rigid,  and  resist  quick  efforts 
at  moving  them.  The  reflexes  are  markedly  increased  both 
in  the  affected  limbs  and  all  over  the  body.  The  muscles 
atrophy  slowly  from  disease,  and  after  some  time  contractures 
of  the  affected  parts  take  place  with  the  joints  in  flexion. 
Athetoid  movements  are  also  regularly  present.  Efforts  at 
walking  are  usually  associated  with  such  a  tendency  to 
adductor  contraction  as  to  cross  the  legs  over  each  other. 
The  mental  faculties  are  more  or  less  impaired,  sometimes  to 
complete  idiocy.  Speech  is  usually  imperfect,  and  hearing 
and  sight  may  be  defective. 

The  acquired  variety  is  apt  to  begin  with  a  convulsion,  fol- 
lowed by  fever  and  symptoms  like  meningitis,  but  with  hemi- 
plegia left  behind.  In  these  cases  the  mental  condition  is 
more  nearly  normal  than  in  the  congenital  or  birth  palsies. 

Many  of  the  congenital  and  birth  cases  give  a  history 
lending  us  to  believe  them  acquired,  as  the  mother  thinks  the 
child  was  normal  for  some  months  after  birth,  but  more  care- 
ful observation  would  decide  otherwise. 

Diagnosis:  Cerebral  palsies  differ  from  spinal  paralysis  by 
having  rigid  muscles,  and  not  flaccid,  atrophied  ones.  The 
reaction  of  degeneration  is  not  present.  The  acquired  form 
may  suggest  meningitis  in  its  onset;  but  the  quick  recovery 
from  the  acute  symptoms,  with  paralysis  left,  soon  decides 
the  diagnosis. 

1 1  is  well  to  discover,  if  possible,  for  the  sake  of  prognosis, 
whether  the  case  is  congenital,  due  to  birth-trauma,  or  ac- 
quired. 

19—1).  C. 


290  DISEASES   OF  THE  NERVOUS  SYSTEM. 

Prognosis :  This  is  better  in  the  acquired  hemiplegia  than 
in  the  diplegias  or  paraplegias  of  congenital  or  birth-origin. 
None,  however,  recover  completely  without  some  mental  im- 
pairment in  addition  to  the  physical  deformity,  and  all  are 
subject  to  epilepsy. 

Infantile  cerebral  palsy — treatment :  During  an  acute  attack 
treat  as  meningitis,  by  a  purge,  ice  to  the  head,  and  bromides 
internally. 

After  this,  attend  to  the  general  health,  and  prevent  de- 
formities by  the  use  of  proper  apparatus.  If  deformity  is 
present,  perform  tenotomies  and  apply  braces.  These  chil- 
dren are  fit  subjects  for  education  in  institutions  for  the 
feeble-minded.  In  cases  of  epilepsy  bromides  and  surgery 
are  our  recourse. 


IDIOCY  AND  IMBECILITY. 

The  difference  between  an  idiot  and  an  imbecile  is  one  of 
degree  only.  Both  are  permanent  conditions  due  to  changes 
in  the  cerebrum,  which  may  be  an  arrest  of  development  of 
a  congenital  nature ;  or  the  result  of  inflammatory  or  trau- 
matic injury,  or  premature  ossification  of  the  skull. 

An  idiot  has  his  intellectual  faculties  completely  impaired, 
and  is  really  little  more  than  an  animal  in  human  form.  An 
imbecile  is  often  called  simply  a  feeble-minded  person,  and  is 
really  a  high-grade  idiot.  His  mental  development  is  often 
fair,  but  his  self-control  and  emotional  faculties  are  very  de- 
ficient. 

Idiocy  and  imbecility — symptoms  :  The  main  sign  is  the  in- 
ability of  the  brain  to  receive,  to  utilize,  and  to  produce 
mental  conceptions.  All  varieties,  from  absolute  lack  of  any 
mental  action  to  simply  an  unbalanced  mental  deficiency,  are 
seen.  The  least  marked  cases  are  the  "  backward  "  children 
in  a  family  or  in  school. 

In  many  of  them  the  moral  nature  seems  absolutely  lack- 
ing, although  they  may  be  bright  and  quick  at  most  things. 
This  is  the  class  that  furnishes  a  large  number  of  the  habitual 
criminals  to  society.     In  other  words,  they  are  degenerates. 

Deficient  mental  development  may  appear  evident  in  chil- 


CRETINISM.  291 

dren  at  a  very  early  age,  but  the  milder  degrees  are  usually 
not  discovered  until  much  later. 

Physical  signs  are  frequently  seen  which  should  attract  our 
attention  to  the  condition.  Among  these  are  a  microcephalic 
or  a  misshapen  skull,  with  a  markedly  receding  forehead. 
The  so-called  stigmata  of  degeneration  may  be  present,  high 
arched  palate,  prognathism,  irregularities  in  the  teeth,  mal- 
formations in  the  ears,  anomalies  in  the  fingers,  and  left- 
handedness.  These  children  are  apt  to  be  restless,  continually 
walking  about,  or  keeping  some  limb  in  motion,  and  they  go 
through  various  purposeless  performances  repeatedly. 

Diagnosis :  A  little  observation  of  the  mental  and  physical 
condition  rapidly  makes  the  diagnosis  sure.  It  is  well  to  at- 
tempt to  find  the  origin  of  the  condition,  whether  it  is  con- 
genital or  acquired. 

Prognosis :  This  is  absolutely  bad  as  regards  the  mental 
defect.  It  has,  however,  no  bearing  on  the  prolongation  of 
life. 

Idiocy  and  imbecility — treatment :  Much  can  be  accom- 
plished in  developing  any  dormant  intellect  in  these  children 
by  education  in  a  thoroughly  equipped  institution. 

CRETINISM. 

Definition:  This  disease  consists  in  the  arrested  physical 
and  mental  development  of  a  child.  It  occurs  endemically 
in  certain  portions  of  the  world,  and  sporadically  in  our 
country,  being  fairly  common  now  that  it  is  more  often  looked 
for. 

Etiology :  The  condition  is  due  to  the  loss  of  function  of 
the  thyroid  gland.  The  gland  may  be  congenitally  absent, 
or  its  glandular  structure  may  be  replaced  by  other  tissue,  or 
the  organ  may  have  been  removed  by  surgical  means. 

Cretinism — symptoms :  The  characteristic  signs  of  the  dis- 
ease may  appear  during  the  first  year  of  life,  or  nol  until 
later.  They  develop  rather  slowly,  but  steadily  become  more 
marked.  When  well  developed  the  appearance  is  unmis- 
takable. The  child  is  short  in  stature,  and  light  in  weight 
for  its  age.     The  limbs   and   lingers  and   toes  are  short  and 


292  DISEASES  OF  THE  NERVOUS  SYSTEM. 

thick.  The  fontanelle  is  very  late  in  closing,  the  nose  is  flat, 
broad  and  upturned,  the  alee  being  thick,  and  the  nostrils 
wide  open.  The  lips  are  much  thickened,  and  the  tongue  is 
large  and  constantly  protruded.  The  teeth  are  cut  late,  and 
are  badly  formed  and  irregularly  placed.  The  hair  is  sparse, 
but  coarse  and  straight.  The  skin  of  the  entire  body  is  thick 
and  dry,  but  does  not  pit  on  pressure.  In  the  supraclavicular 
regions  there  are  regularly  formed  pads  of  fatty  tissue,  which 
give  the  neck  a  shortened,  thickened  appearance.  The  thyroid 
gland  can  usually  not  be  felt  unless  it  contains  a  tumor.  The 
abdomen  is  large  and  prominent,  and  an  umbilical  hernia  is 
frequently  present. 

Walking  and  talking  are  learned  late,  and  are  very  im- 
perfectly performed  even  then.  The  sexual  functions  are 
developed  very  late  in  life  ;  in  fact,  the  infantile  condition 
persists  over  many  years.  Constipation  is  often  found,  which 
seems  to  be  directly  due  to  the  cretinoid  condition,  as  it 
usually  disappears  quickly  under  treatment. 

The  temperature  is  apt  to  be  subnormal,  and  the  mental 
condition  is  one  of  extreme  apathy  and  dulness. 

Diagnosis  :  It  is  very  important  to  make  an  early  diagnosis, 
as  when  treatment  is  begun  then  the  child  may  be  brought 
back  to  virtually  a  normal  state.  By  a  little  care,  after  one 
or  two  well-developed  cases  have  been  seen  and  their  typical 
appearance  well  impressed  on  the  mind,  the  condition  should 
not  be  overlooked  even  in  its  ineipiency. 

Prognosis :  If  untreated,  the  cases  grow  worse  and  worse. 
Treatment  begun  early  seems  to  be  able  to  eradicate  the 
effects  of  the  disease.  When  begun  late  great  improvement 
occurs,  but  probably  the  child  will  never  become  normal. 
The  physical  improvement  is  more  marked  than  the  mental. 
Under  any  circumstances  "  thyroids "  have  to  be  given  in- 
definitely to  prevent  recurrence. 

Cretinism — treatment :  Thyroid  extract  daily  by  mouth  in 
doses  of  one  to  five  grains  replaces  in  the  system  the  active 
principle  of  the  normal  thyroid  gland.  At  the  same  time 
attention  to  the  diet,  exercise,  fresh  air,  and  the  moral 
and  mental  education  of  the  child  are  of  the  utmost  impor- 
tance. 


3  I 

o    S- 


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O    C 


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CONVULSIONS.  293 


CONVULSIONS. 


Spasmodic  contractions  of  the  muscles  are  very  common  in 
infancy.  They  are  often  called  eclampsia.  They  are  to  be 
looked  on  as  a  symptom  of  disturbance  in  the  motor  area  of 
the  brain  due  to  various  causes. 

Convulsions — etiology  :  The  great  predisposing  cause  is  the 
markedly  increased  excitability  of  the  lower  reflex  centers  of 
the  nervous  system,  and  the  poor  development  of  the  higher 
inhibitory  centres  in  infancy. 

Nutritive  disorders  increase  this  tendency  by  interfering 
with  the  proper  nutrition  of  the  nervous  centres.  Rickets, 
ansemia,  malnutrition,  and  intestinal  diseases  are  of  greatest 
importance  as  predisposing  causes.  An  hereditary  neurotic 
taint  is  also  a  great  predisposer  to  convulsions. 

Exciting  causes  are  various,  and  often  seemingly  unim- 
portant. All  inflammations,  injuries,  and  pathological  lesions 
of  the  brain  are  apt-  to  be  causes  of  convulsions.  Irritation 
from  trauma  elsewhere  on  the  body ;  from  renal,  hepatic,  or 
intestinal  colic  ;  from  undigested  food  ;  from  phimosis  ;  from 
foreign  body  in  the  ear,  and  probably  from  dentition  and 
worms,  may  start  a  general  convulsion.  Finally,  fever  from 
any  cause,  as  heat-stroke,  or  the  beginning  of  an  infectious 
disease,  is  a  very  frequent  exciting  cause. 

While  in  most  cases  some  cause,  direct  or  indirect,  may  be 
found  ;  still  there  are  a  good  many  that  must  be  called  idio- 
pathic. 

Pathology :  The  probable  lesion  is  a  hypersemic  condition 
of  the  motor  region  of  the  brain. 

Convulsions — symptoms :  There  may  be  prodromal  symp- 
toms  of  restlessness,  twitchings  of  the  facial  muscles,  grind- 
ing of  the  teeth,  or  rolling  of  the  eyes. 

Usually,  however,  the  general  spasm  comes  on  suddenly 
and  unexpectedly.  The  eyes  become  fixed,  the  jaw  clenched, 
the  skin  pale,  the  limbs  rigid  with  a  tendency  to  flexion  in 
all  the  joints,  and  the  neck  retracted.  Consciousness  is  abol- 
ished. 

This  tonic  contraction  of  the  muscles  may  persist  ;  but  it  is 
usually  followed  by  clonic  contractions,  with  jerking  move- 


294  DISEASES  OF  THE  NERVOUS  SYSTEM. 

ments  of  all  the  limbs.  There  are  then  frothing  at  the 
mouth,  working  of  the  jaw,  irregular  rolling  of  the  eyeballs, 
twitching  of  the  facial  muscles,  and  spasmodic  action  of  the 
muscles  of  the  trunk  and  extremities.  Respiration  is  spas- 
modic, due  to  involvement  of  the  diaphragm.  The  pulse  is 
feeble  and  irregular.  The  skin  and  mucous  membrane  be- 
come cyanotic.  Emptying  of  the  bladder  and  rectum  is 
common. 

These  convulsions  last  from  a  few  minutes  to  an  hour,  and 
leave  the  child  in  a  condition  of  stupor.  They  may  be  re- 
peated after  a  short  or  long  interval  of  quiet.  Multiple  re- 
currences extending  over  many  days  are  fairly  common,  and 
even  then  may  be  followed  by  complete  recovery.  Death 
may  take  place  during  the  first  spasm  or  in  the  subsequent 
ones. 

Localized  spasms  of  certain  regions  may  occur  at  times 
without  meaning  permanent  or  organic  focal  lesion  of  the 
brain. 

Diagnosis  :  The  only  necessity  in  diagnosis  is  to  discover  as 
quickly  as  possible  the  cause  of  the  spasm.  All  the  etiologi- 
cal factors  should  be  taken  up  in  order  and  each  one  ex- 
cluded. In  new-born  babies  the  probabilities  are  in  favor  of 
meningeal  hemorrhage  or  of  tetanus.  In  older  children 
gastro-intestinal  irritations,  or  the  beginning  of  one  of  the 
infectious  fevers,  are  the  commonest  causes.  The  pulse  and 
temperature  should  be  taken,  the  fontanelles  examined,  the 
urine  analyzed,  and  the  history  carefully  investigated  in 
every  case. 

Prognosis :  In  fairly  strong  children,  and  except  when 
actual  brain-lesion  is  present,  convulsions  are  not  commonly 
fatal.  Those  from  reflex  irritation,  and  due  to  fever,  are  or- 
dinarily not  dangerous.  In  very  feeble  children,  and  when 
they  mark  the  beginning  of  intracranial  disease,  they  are 
much  more  serious.  The  possibility  of  the  convulsions  being 
epileptic  must  be  remembered,  as  this  means  recurrences 
during  an  indefinite  number  of  years. 

Convulsions — treatment :  The  child  should  be  kept  as  quiet 
as  possible,  and  all  rubbing  and  unnecessary  manipulation 
forbidden.     A  warm  mustard  bath  or  pack  may  be  given 


TETANY.  295 

until  the  skin  is  reddened.  If  there  is  fever,  a  cool  bath 
should  be  substituted.  Ice  applications  to  the  head  are 
always  helpful. 

During  the  convulsion  the  child  should  be  immediately  put 
under  the  influence  of  chloroform,  and  kept  so  until  the  con- 
vulsive tendency  has  disappeared.  While  anaesthetized  it 
should  be  given  by  rectum  suitable  doses,  for  its  age,  of 
chloral  and  bromide,  which  may  be  repeated  hourly.  If  these 
drugs  fail  to  prevent  recurrences,  it  is  quite  justifiable  to  use 
morphine  hypodermatically  in  proper  dose. 
^  In  cases  where  the  digestive  tract  is  believed  to  be  the 
offender  the  stomach  and  bowels  should  be  emptied  by  wash- 
ing or  drugs.  In  many  cases  a  high  rectal  douche  of  warm 
water  should  be  given.  After  the  spasm  is  controlled  hunt 
for  the  cause,  and  treat  that  condition  to  prevent  recurrence. 

TETANY. 

Definition :  This  is  a  functional  nervous  disease  character- 
ized by  tonic  spasms  in  certain  groups  of  muscles,  especially 
those  of  the  hands  and  feet,  and  occurring  in  paroxysms. 

Etiology :  It  occurs  almost  always  in  infants  who  are  suf- 
fering from  rachitis,  marasmus,  or  other  forms  of  malnutri- 
tion, and  from  gastro-intestinal  disorders. 

The  irritation  of  cold  and  wet,  or  of  indigestible  food,  reg- 
ularly excites  an  attack  in  those  predisposed. 

Pathology  :  There  are  no  lesions  connected  with  the  disease. 
Probably  malnutrition  of  the  nerve-centres  increases  their 
reflex  excitability. 

Tetany — symptoms  :  The  attack  consists  of  tonic  spasms  in 
the  extremities,  and  especially  the  hands  and  feet.  It  begins 
rather  rapidly,  and  is  continuous  over  some  time.  There  are 
no  loss  of  consciousness  and  no  marked  subjective  symptoms. 
Pain  is  caused  by  efforts  at  overcoming  the  spasm,  but  is 
ordinarily  not  spontaneous.  The  typical  position  assumed  in 
the  affected  limits  is  for  the  forearm  to  be  pronated, the  wrist 
flexed,  the  thumb  turned  in,  and  the  lingers  flexed  at  the 
metacarpo-phalangea  1  joints.  In  the  feet  the  position  of 
ecjuino-varus  is  assumed,  with  the  plantar  surface  arched  and 


296  DISEASES  OF  THE  NERVOUS  SYSTEM. 

the  toes  bent.  In  the  more  marked  cases  the  arms  and  legs 
are  adducted,  the  spasm  extending  upward  to  the  upper  arms 
and  thighs. 

The  duration  of  the  attack  is  from  a  few  days  to  several 
weeks,  and  recurrences  are  quite  common. 

Diagnosis :  The  lack  of  unconsciousness,  the  typical  posi- 
tion taken  by  the  extremities,  and  the  presence  of  the  predis- 
posing cause  usually  decide  the  diagnosis.  Trousseau's  symp- 
tom, the  production  or  the  augmentation  of  the  spasm  by 
pressure  on  the  nerve  or  vessels  of  the  affected  limb,  may  be 
used  as  a  diagnostic  sign. 

Prognosis :  It  is  not  a  serious  disease,  and  recovery  from 
the  tendency  to  it,  as  well  as  from  the  attack,  is  to  be  expected. 

Tetany — treatment :  Find  and  remove  the  cause,  which  is 
usually  intestinal.  During  the  spasm  use  chloral,  bromides, 
and  antipyrin  internally.  Attend  to  the  patient's  nutrition 
and  digestion  in  order  to  prevent  recurrences. 

EPILEPSY. 

Definition:  This  is  a  functional  neurosis  characterized  by 
convulsions,  which  are  accompanied  by  loss  of  consciousness. 

Etiology  :  The  disease  most  commonly  develops  in  children 
approaching  puberty,  although  cases  are  seen  much  younger. 
A  neurotic  or  alcoholic  heredity  predisposes  to  epilepsy.  It 
develops  often  after  convulsions  occurring  in  infancy,  and  in 
children  suffering  from  cerebral  palsies. 

In  a  predisposed  individual  sudden  fright,  traumatism  to 
the  head,  great  emotional  excitement,  or  excessive  heat  will 
develop  the  disease.  Adenoids,  phimosis,  foreign  bodies  in 
the  ear,  menstrual  disorders,  masturbation,  and  intestinal  tox- 
aemia are  often  causative  factors. 

Pathology  :  There  are  no  discoverable  lesions  of  the  disease. 
It  must  be  looked  upon  as  an  explosion  of  energy  in  the  cere- 
bral cortex. 

Epilepsy — symptoms  :  There  are  two  distinct  types  of  the 
disease,  the  grand  mal  and  the  petit  mal. 

The  grand,  mal  variety  consists  of  a  sudden  attack  of  un- 
consciousness, the  patient  falling  to  the  floor  with  a  sharp  cry, 


EPILEPSY.  297 

the  eyeballs  rolling  up,  the  jaw  set,  and  all  the  muscles  of  the 
body  in  tonic  spasm.  The  skin  becomes  cyanotic;  the  bladder 
and  rectum  may  be  evacuated. 

This  condition  is  succeeded  after  a  few  seconds  by  the  sec- 
ond stage,  that  of  clonic  spasms.  During  this  stage  the  mus- 
cles alternately  contract  and  relax  violently.  The  jaw  is 
moved  up  and  down,  the  tongue  is  apt  to  be  bitten,  there  is 
frothing  at  the  mouth,  and  the  head  is  twisted  to  one  side. 
The  extremities  relax  and  then  become  rigid,  the  muscles  of 
respiration  again  begin  action,  and  the  cyanosis  passes  off. 

This  clonic  stage  gradually  disappears,  the  patient  regains 
consciousness  for  a  moment,  and  then  passes  into  a  deep  sleep 
of  exhaustion  lasting  some  hours.  After  awaking  he  has  no 
recollection  of  what  has  happened. 

The  petit  mal  variety  consists  essentially  in  a  sudden,  short 
loss  of  consciousness,  coming  on  while  the  child  is  engaged  in 
any  action,  lasting  a  few  seconds ;  and  after  it  is  over,  im- 
mediate resumption  of  what  was  being  done  before,  without 
recollection  of  the  interruption.  The  child  does  not  fall,  but 
usually  remains  fixed  in  whatever  position  it  occupied  before 
the  onset,  while  the  eyes  have  a  vacant  stare. 

In  either  variety  there  is  often  preceding  the  attack  a 
warning  or  premonition  of  its  advent.  This  is  called  the 
aura,  and  when  present  it  is  usually  the  same  before  each 
convulsion,  and  may  be  motor  or  referred  to  any  one  of  the 
senses. 

The  seizures  are  repeated  at  irregular  intervals,  growing 
usually  more  frequent  as  time  passes,  and  often  recurring 
many  times  in  the  same  day. 

They  occur  both  by  night  and  by  day,  and  both  types  may 
be  seen  in  the  same  individual. 

Diagnosis :  Hysterical  convulsions  are  to  be  excluded  by 
differences  in  the  character  of  the  movements,  and  by  the 
presence  of  consciousness  and  recollection  of  the  event. 
Ureemic  convulsions  are  proved  by  examination  of  the  urine. 
Diseases  of  the  brain  produce  more  localized  convulsions, 
and  leave  some  evidence  of  their  occurrence  after  they 
pass  off. 

In  cases  suffering  from  petit  mal  only,  observation  must  be 


298  DISEASES   OF  THE  NERVOUS  SYSTEM. 

continued  over  some  time  before  a  diagnosis  may  be  positively 
made. 

Prognosis  :  The  danger  to  life  consists  in  a  serious  accident 
happening  to  the  child  during  the  unconsciousness  of  the  con- 
vulsion, as  falling  in  the  fire,  or  in  front  of  a  car,  or  from  a 
height. 

If  the  cases  are  recognized  early  and  a  cause  found  that  is 
removable,  the  chances  of  cure  are  fair.  In  the  old  cases 
treatment  seems  only  to  lessen  the  number  of  convulsions. 
Surgery  has  helped  some  of  the  cases  where  a  local  lesion  was 
suspected  in  the  skull. 

Epilepsy — treatment :  During  the  attack  simply  prevent 
the  child  from  injuring  itself  or  biting  its  tongue.  Epileptics 
should  always  have  a  companion.  Discover,  if  possible,  any 
cause,  direct  or  reflex,  and  remove  it,  going  systematically 
through  the  whole  list  of  etiological  factors.  Regulate  all 
the  functions,  particularly  the  digestive,  in  the  most  careful 
way.  Insist  on  the  proper  amount  of  exercise,  sleep,  fresh 
air,  proper  clothing,  proper  food,  regulation  of  the  school-  and 
play-hours,  and  on  suitable  domestic  surroundings. 

As  drugs,  the  bromides  given  in  full  doses  over  a  consider- 
able length  of  time  are  the  most  valuable  therapeutic  help  we 
have.  In  petit  mal  belladonna  combined  with  the  bromides 
seems  helpful. 

In  traumatic  epilepsy,  where  a  localized  depression  is  found 
in  the  skull,  cerebral  surgery  may  be  tried  with  some  hopes 
of  success. 

CHOREA. 

Definition  :  The  ordinary  name  for  this  disease  is  St.  Vitus' 
dance.  It  is  a  functional  neurosis  characterized  by  irregular 
rapid  twitchings  of  a  few  or  all  of  the  muscles  of  the  body. 

Etiology :  It  occurs  most  commonly  from  the  seventh  to 
the  fourteenth  year,  and  more  often  in  girls  than  in  boys. 
Children  born  of  neurotic  or  alcoholic  parents  are  predisposed 
to  the  disease.  It  often  follows  scarlet  fever  or  other  of  the 
infectious  diseases.  Many  cases  develop  in  ana?mic  children. 
Of  all  causes,  however,  the  rheumatic  diathesis  is  most  often 
present  in  the  subjects  of  chorea. 


CHOREA.  299 

The  exciting  cause  of  an  attack  is  often  a  great  fright,  or 
overwork  at  school,  or  the  presence  of  adenoids,  worms,  or 
phimosis.  The  early  evidences  of  beginning  menstruation 
are  often  exciting  factors. 

Pathology :  The  pathological  condition  present  is  probably 
some  disturbance  in  the  nutrition  of  the  nerve-centres  in  the 
motor  areas  in  the  brain. 

Chorea — symptoms  :  The  attack  usually  develops  gradually, 
with  clumsiness  on  the  part  of  the  child  in  making  voluntary 
movements  with  the  extremities  to  be  affected.  Twitching 
of  the  facial  or  trunk  muscles  may  be  first  noted.  Soon  the 
typical,  irregular,  spasmodic  movements  of  these  muscles  de- 
velop, until  the  child  can  only  with  difficulty  use  the  limbs, 
the  chronic  jerkings  interfering  with  the  normal,  intentional 
motions.  The  less  observed  and  quieter  the  child  keeps  the 
less  marked  are  the  movements.  When  noticed,  or  when  de- 
siring to  make  some  muscular  movement,  the  chorea  becomes 
worse.  The  same  is  true  under  efforts  to  control  them.  The 
movements  usually  cease  during  sleep. 

The  affected  muscles  are  weak,  and  the  mental  condition 
of  the  child  one  of  extreme  irritability.  The  speech  is  regu- 
larly involved  and  at  times  very  difficult  to  understand. 

On  examining  the  heart,  in  a  large  majority  of  the  cases,  a 
soft  systolic  murmur  is  heard  over  the  mitral  or  pulmonic 
area.  In  many  children  this  disappears  after  recovery,  in 
which  case  it  was  probably  anaemic;  but  in  others  it  remains 
permanent,  when  it  was  probably  a  rheumatic  endocarditis. 
These  children  are  regularly  anaemic,  with  poor  appetites  and 
disturbed  sleep,  and  other  evidences  of  disturbed  nutrition. 

The  attacks  last  ordinarily  from  two  to  three  months. 
Some  become  chronic  and  may  last  for  years.  Recurrences 
arc  rather  to  be  expected  even  after  complete  recovery. 

Diagnosis:  This  is  usually  easy.  Tic  convulsif,  due  to 
irritation  of  the  fifth  nerve,  may  be  mistaken  for  chorea,  but 
is  never  found  outside  the  distribution  of  this  nerve. 

Prognosis:  Chorea  may  be  so  severe  as  to  endanger  life  in 
itself,  or  from  endocarditis,  but  this  is  rare  in  childhood. 
Recovery  is  usually  complete  in  the  ordinary  cases,  the  heart- 
lesion  of  the  rheumatic  diathesis  being  the  only  serious  re- 


300  DISEASES  OF  THE  NERVOUS  SYSTEM. 

mainder.  Recurrences  after  some  months  or  about  an  even 
year  may  be  looked  for. 

Chorea — treatment :  The  child  should  be  taken  from  school, 
and  kept  comparatively  quiet  in  one  room,  and  should  not  be 
allowed  to  see  too  many  visitors.  The  diet  should  be  simple 
and  easy  to  digest,  and  the  room  kept  properly  ventilated. 

If  there  are  evidences  of  rheumatism  present,  salicylate  of 
sodium  should  be  used.  For  the  chorea  itself,  arsenic,  given 
in  the  form  of  Fowler's  solution  in  gradually  increasing  doses 
to  tolerance,  is  almost  a  specific.  Iron  in  some  easily  assimi- 
lable form  is  advantageously  combined  with  it.  In  cases 
where  the  spasmodic  movements  are  very  excessive  bromides, 
or  chloral,  or  both,  may  be  given  at  the  same  time  to  dull  the 
reflex  irritability  of  the  nervous  system. 

HYSTERIA. 

Hysteria,  while  rare  in  childhood,  is  still  seen  at  times  in 
certain  of  its  phases. 

Etiology :  The  disease  is  seldom  seen  before  the  tenth  year, 
and  occurs  as  often  in  boys  as  in  girls.  A  neurotic  or  alco- 
holic heredity  is  usually  present.  Malnutrition  and  improper 
school  and  home  education  and  surroundings  are  most  im- 
portant etiological  factors.  The  modern  forcing  forward 
of  children  is  responsible  for  much  of  it.  Some  sudden  ex- 
ternal irritation  to  the  nervous  system  awakes  the  attack. 

Pathology :  There  are  no  known  pathological  changes  in 
this  disease. 

Hysteria — symptoms :  Almost  any  of  the  varied  symptoms 
of  disease   may  be   simulated   by  hysteria. 

Sensory  disturbances  are  quite  common,  hyperesthesia  of 
almost  any  of  the  superficial  or  deep  structures  of  the  body 
being  often  present,  such  as  headaches,  joint-pains,  and  ab- 
dominal tenderness.  Blindness  and  deafness  may  also  occur. 
Anaesthesia  is  less  frequent,  but  is  also  found. 

In  the  motor  sphere  various  forms  of  paralysis  are  com- 
mon. Aphonia,  monoplegia,  or  even  paraplegia  may  develop. 
Various  contractures  in  the  extremities  are  quite  common. 
The  most  frequent  motor  symptom,  however,  is  the  hysterical 


HYSTERIA.  301 

convulsion.  The  child  screams,  or  laughs,  or  cries,  and  rolls 
around,  throwing  the  limbs  in  irregular  purposeless  move- 
ments. Opisthotonos  is  frequent,  but  the  patient  never  hurts 
himself  as  in  epilepsy.  Consciousness  is  retained,  and  there 
is  present  afterward  a  remembrance  of  the  fit. 

Psychical  symptoms  are  often  seen — morbid  appetite,  refusal 
of  food,  craving  for  sympathy,  increased  self-consciousness, 
and  depressed  states  bordering  on  melancholia.  In  others 
there  are  great  excitability  and  fits  of  ungovernable  passion. 
Hallucinations,  night-terrors,  and  disturbed  sleep  are  fre- 
quent. Symptoms  of  more  than  one  variety  are  often  seen 
in  the  same  patient. 

Diagnosis :  Observation  over  a  prolonged  period  of  time  is 
often  necessary  before  organic  disease  can  be  excluded.  The 
possibility  of  the  two  conditions  being  present  at  the  same  time 
must  not  be  forgotten.  Eventually  the  diagnosis  becomes 
quite  easy  and  positive. 

Prognosis:  This  is  not  very  good.  Periods  of  improvement 
are  seen,  but  relapses  are  common,  and  later  in  life  these 
patients  usually  become  highly  neurotic. 

Hysteria — treatment :  Everything  possible  should  be  done 
to  improve  the  general  health  and  nutrition  of  these  children. 
Fresh  air,  proper  exercise,  regulation  of  the  bowels,  easily 
digested  and  simple  food;  regulation  of  the  work  and  the 
recreation  ;  avoidance  of  novels,  theatres,  and  unsuitable  as- 
sociates, are  all  points  for  medical  supervision.  Often  a  great 
deal  is  accomplished  by  removing  them  from  family  and 
friendly  influences,  and  putting  them  under  the  charge  of  a 
suitable  individual  who  will  treat  them  with  firmness  and 
tact.  In  other  words,  the  treatment  is  entirely  hygienic  and 
moral. 

Hysterical  symptoms  as  they  arise  may  call  for  treatment, 
and  some  rather  unpleasant  variety  should  be  tried  for  each 
symptom,  ;i-  counter-irritation,  electricity,  cold  douches,  and 
other  similar  therapeutical  means,  any  one  of  which  will  ap- 
peal to  the  child  from  the  standpoint  of  suggestion. 


302  DISEASES  OF  THE  NERVOUS  SYSTEM. 

HEADACHES. 

Headaches  are  fairly  common  in  children,  especially  in  girls 
approaching  puberty.  In  infants  they  are  rare,  except  as  a 
symptom  of  organic  disease  of  the  brain. 

Etiology :  The  commonest  causes  are  anaemia  and  other 
forms  of  malnutrition ;  constant  breathing  of  impure  air 
charged  with  carbonic  acid  gas  and  other  impurities ;  chronic 
indigestion  and  constipation,  with  absorption  of  products  of 
intestinal  decomposition ;  uraemia,  malaria,  the  rheumatic 
diathesis ;  and,  reflexly,  diseases  and  anomalies  of  the  eyes, 
nose,  and  ears.  A  large  class  includes  the  so-called  nervous 
headaches,  in  which  there  seems  simply  a  tendency  for  the  brain 
to  ache  under  some  unknown  circumstances.  These  are  usually 
children  of  a  neurotic  heredity.  Another  class  are  the  sick 
headaches,  in  which  nausea  and  vomiting  accompany  the  pain. 
These  are  probably  due  to  a  toxaemia  from  an  excess  of  the 
end-products  of  proteid  metamorphosis  in  the  blood. 

Pathology  :  The  changes  in  the  brain  that  cause  pain  are 
probably  entirely  circulatory. 

Headaches — symptoms:  Pain  in  the  head  is  the  symptom. 
It  may  be  localized  or  diffuse.  It  may  be  one-sided  or  on 
both  sides.  It  may  be  accompanied  by  symptoms  elsewhere, 
as  nausea  and  vomiting,  or  rheumatism,  or  other  sign  point- 
ing to  the  etiology. 

Diagnosis :  The  only  point  in  diagnosis  is  to  discover  the 
cause.  Go  carefully  through  all  the  possibilities,  and  observe 
the  child  closely,  excluding  one  cause  after  another,  and  even- 
tually it  can  be  decided  in  most  cases  to  what  the  headaches 
are  due. 

Headaches — treatment :  To  cure  the  attack,  phenacetin  and 
caffeine  are  the  main  drugs  of  value.  They  may  be  combined 
with  cold  applications  to  the  head  and  hot  mustard  foot-baths. 

After  the  attack  is  over  treat  the  cause  if  it  can  be  found. 
Enrich  the  blood,  improve  the  nutrition,  regulate  the  diet  and 
the  bowels,  remove  malarial,  rheumatic,  or  lithsemic  tenden- 
cies, see  that  the  kidneys  secrete  properly,  correct  errors  of 
refraction  in  the  eyes,  and  cure  nasal,  nasopharyngeal,  and 
ear  affections. 


SPEECH-DISORDERS.  303 


SPEECH-DISORDERS. 


We  are  frequently  consulted  for  advice  about  the  various 
functional  difficulties  of  speech  which  are  so  common  in  chil- 
dren. 

Varieties  :  The  main  forms  are  late  development  of  speech, 
lisping,  stuttering,  and  aphasia. 

Late  development  of  speech :  Most  children  should  learn 
to  talk  during  the  second  year  of  life.  Much  depends,  how- 
ever, on  efforts  made  to  teach  them.  In  children  with  no 
training,  or  in  those  who  have  been  seriously  debilitated  by 
sickness,  the  function  of  speech  may  be  much  delayed  even 
when  there  is  no  brain-defect.  Time  and  a  little  attention 
will  quickly  remedy  this.  Very  late  speech  is  suspicious  of 
cerebral  anomaly. 

Lisping :  This  consists  in  an  inability  to  articulate  clearly 
the  hissing  sounds.  It  may  be  simply  a  habit;  but  at  times 
it  seems  almost  impossible  to  place  the  tongue  and  teeth  and 
lips  in  such  a  position  as  perfectly  to  form  these  sounds.  It 
is  never  a  serious  defect,  and  can  usually  be  overcome  by 
proper  training  begun  early  before  the  habit  becomes  too 
fixed. 

Stuttering :  Stammering  is  a  term  also  used  almost  inter- 
changeably with  this.  It  is  rare  before  the  second  dentition, 
and  consists  in  an  inability  to  connect  consonants  and  vowels 
together  into  a  continuous  word.  Certain  consonants  seem 
especially  hard  to  enunciate.  Singing  is  often  done  with  no 
hesitation. 

Stuttering  is  likely  to  develop  in  children  of  neurotic  hered- 
ity, in  those  who  are  overworked  at  school,  and  in  the  badly 
nourished.  In  some  it  is  an  imitative  habit.  Removal  of  the 
cause  and  improvement  of  the  general  health  will  often  cure 
the  habit.  In  the  older  eases  a  process  of  careful  training  in 
enunciation  and  use  of  the  voice,  by  a  person  skilled  in  such 
work,  should  be  undertaken. 

Aphasia:  By  this  is  meant  a  temporary  functional  hiss  of 
speech,  not  the  form  due  to  disease  of  the  third  left  frontal 
convolution.  It  is  -ecu  ;it  times  after  severe  attacks  of  ill- 
ness, as  typhoid    fever,  and  after  marked   emotional   excite- 


304  DISEASES  OF  THE  NERVOUS  SYSTEM. 

ment.     It  usually  recovers  spontaneously  in  a  comparatively 
short  time. 

SLEEP-DISORDERS. 

There  are  frequently  found  in  children  disturbances  of 
sleep.  The  two  of  most  importance  are  marked  restlessness, 
amounting  almost  to  insomnia,  and  night-terrors.  The  two 
conditions  may  be  treated  together,  as  they  seem  to  depend 
on  similar  causes  and  to  differ  in  degree  only. 

Etiology :  The  commonest  causes  are  derangements  of  the 
digestive  tract,  due  to  improper  feeding  in  some  way,  either 
over-feeding  or  under-feeding,  or  the  giving  of  unsuitable 
forms  of  food.  This  leads  to  colicky  pains,  to  chronic  indi- 
gestion, and  to  absorption  into  the  blood  and  circulation 
through  the  brain  of  intestinal  toxins.  Earache,  obstructed 
respiration  (the  result  of  adenoids  or  other  causes),  and  general 
nervous  irritability  from  excessive  fatigue,  reading  or  hearing 
exciting  stories,  and  improper  home-surroundings,  are  the 
common  causes  of  many  cases. 

Sleep-disorders — symptoms  :  There  may  be  only  a  restless, 
disturbed  sleep,  with  frequent  waking ;  or  an  actual  insomnia. 
This  latter  is  comparatively  rare  in  children. 

In  night-terrors  the  child  suddenly  awakes  from  his  sleep 
in  great  fright,  half  remembering  some  dreadful  dream.  At 
first  he  is  bewildered ;  but  gradually  his  mind  becomes  clear, 
and  after  a  time  he  goes  off  to  sleep  again.  Recurrences  are 
frequent. 

Diagnosis  :  This  is  fairly  easy.  The  night-terrors  might  be 
confused  with  nocturnal  epilepsy  ;  but  a  little  careful  observa- 
tion will  usually  settle  the  diagnosis. 

Prognosis:  This  is  good,  as  by  proper  treatment  the  con- 
dition can  be  cured. 

Sleep-disorders — treatment :  Find  the  cause,  if  possible, 
and  remove  it.  Regulate  the  diet,  the  bowels,  the  exercise, 
the  reading  of  books,  and  listening  to  stories.  Improve  the 
general  health  in  every  way.  Give  no  drugs,  if  possible  to 
dispense  with  them.  If  necessary,  use  trional  or  bromides, 
given  at  bedtime. 


BAD  HABITS.  305 

BAD  HABITS. 

The  two  bad  habits  that  are  most  often  seen  in  children  are 
sucking  and  masturbation.     The  former  may  lead  to  the  latter. 

Sucking  :  This  is  very  common.  It  consists  in  sucking  of 
the  fingers,  or  toes,  or  some  foreign  substance,  such  as  a  rub- 
ber-nipple. Often  the  fingers  will  be  sucked  so  constantly  as 
to  produce  distinct  maceration  of  the  skin.  In  addition  to 
its  being  a  bad  habit,  probably  the  baby  sucks  some  wind 
into  its  stomach  by  its  persistent  efforts.  Great  pains  should 
be  taken  in  the  beginning  to  prevent  the  formation  of  the 
habit  before  it  becomes  so  fixed  as  to  be  hard  to  cure.  Often 
the  fingers  will  have  to  be  bandaged  and  tied. 

Masturbation :  Masturbation,  it  must  not  be  forgotten,  is 
quite  common  among  small  children  of  both  sexes,  and  is 
even  seen  in  babies  of  a  year  old.  It  may  result  from  local 
irritation  of  the  genitals,  as  from  phimosis,  worms,  vulvitis, 
itching  skin-diseases,  or  irritating  urine.  Other  cases  are 
taught  by  forms  of  play  or  exercise  in  which  friction  is  made 
on  the  genitals ;  and  still  others  by  playmates  or  nurses.  It 
may  be  performed  by  use  of  the  hands,  or  by  rubbing  the 
thighs  together,  or  by  friction  against  some  external  object. 
Children  the  subject  of  this  habit  are  apt  to  be  anaemic  and 
poorly  nourished  and  irritable.  Locally  the  genitals  are 
relaxed,  and  there  may  be  slight  redness  of  the  prepuce  or 
vulva.  Careful  observation  extended  over  some  time  is 
necessary  to  detect  these  cases.  The  younger  the  child,  and 
the  sooner  the  habit  is  discovered,  the  more  apt  will  we  be  to 
break  the  indulgence. 

Masturbation — treatment :  Intelligent  moral  care  from  the 
parents  is  of  most  value.  Any  local  cause  of  irritation  should 
be  removed.  The  general  health  particularly  should  be  im- 
proved in  every  way.  Mechanical  restraints  may  help  in 
very  young  children,  but  are  useless  in  older  ones.  The 
child's  companions  should  be  carefully  selected.  Hypnotism 
has  been  of  value  in  some  cases.  Corporal  punishment  will 
not  often  be  of  much  use,  except  in  individual  cases  where 
the  child's  temperamenl  is  such  as  to  be  much  influenced  by 
this  kind  of  treatment.  Many  of  the  cases  arc  very  difficult 
to  handle. 

20— 1).  C. 


CHAPTER    XII. 

DISEASES   OF  THE   LYMPH-NODES. 

ACUTE  ADENITIS. 

Definition :  This  is  an  acute  exudative  inflammation  of  the 
lymphatic  glands.     It  is  exceedingly  common  in  children. 

Etiology  :  This  is  probably  always  secondary  to  an  abrasion 
or  inflammation,  of  one  kind  or  another,  of  the  skin,  or 
mucous  membrane  of  the  area  drained  into  the  inflamed 
glands.  The  original  lesion  may  be  so  inconspicuous  as  to  be 
overlooked.  The  commonest  causes  are  rhinitis,  naso-pharyn- 
gitis,  stomatitis,  dentition,  otitis,  eczema,  diphtheria,  scarlet 
fever,  measles,  and  influenza.  From  these  the  cervical  glands 
are  affected.  The  axillary  glands  are  involved  from  vacci- 
nation, paronychia,  trauma  to  the  hand  or  arm,  or  skin-erup- 
tions on  the  same.  The  inguinal  glands  inflame  from  lesions 
about  the  genitals,  anus,  or  feet. 

Adenitis  is  most  frequent  during  the  first  two  years  of  life, 
the  absorptive  power  of  the  lymphatics  seeming  most  active 
then.  It  occurs  in  both  healthy  and  delicate  children,  but 
seems  most  frequent  among  those  in  institutions. 

Pathology :  The  glands  are  swollen,  infiltrated  with  the 
products  of  exudation,  and  the  surrounding  tissues  are  usually 
involved.  If  the  infection  is  severe  enough,  there  is  such  an 
excessive  emigration  of  white  cells  as  to  cause  the  glands  to 
break  down  and  form  abscesses.  The  milder  cases  go  on  to 
resolution  with  absorption  of  the  inflammatory  products. 

Acute  adenitis — symptoms :  Most  of  the  cases  have  some 
fever,  which  may  reach  102°  F.  or  more,  with  its  accompany- 
ing malaise.  The  inflamed  glands  are  swollen,  a  little  pain- 
ful, and  usually  quite  tender.  When  under  the  sterno-mas- 
toid  muscle  a  voluntary  torticollis  is  often  caused.  When 
only  the  gland  is  involved  the  skin  retains  its  normal  color; 
but  if  the   surrounding    tissue   becomes  inflamed,   the  skin 

306 


CHRONIC  ADENITIS.  307 

reddens.  These  are  the  cases  apt  to  suppurate.  Only  one, 
or  a  number  of  neighboring  glands,  may  be  affected,  and  in 
some  cases  groups  in  separate  locations  are  involved  simul- 
taneously. The  tumor  may  reach  the  size  of  an  egg.  It 
remains  hard  and  regular,  unless  it  suppurates,  when  soft 
spots  may  be  felt  on  its  surface. 

In  cases  complicating  infectious  fevers  the  local  swelling 
and  tenderness  are  all  that  can  be  recognized  during  the 
symptoms  of  the  original  disease.  In  cases  in  which  there  is 
suppuration  softening  usually  occurs  by  the  second  week,  fol- 
lowed by  bursting  externally.  After  evacuation,  natural  or 
artificial^  healing  is  usually  rapid  and  complete.  In  non-sup- 
purative  cases  the  acute  stage  passes  away,  and  the  swelling 
gradually  is  absorbed,  requiring  a  month  or  two. 

Diagnosis :  Knowledge  of  the  location  of  the  superficial 
lymphatic  glands,  and  the  fact  that  the  swelling  is  only  of 
short  duration,  cover  every  point  in  diagnosis. 

Prognosis:  This  is  good  except  in  seriously  debilitated 
children.  Recovery  is  usually  rapid.  Some  few  become 
chronic  and  are  later  infected  by  the  tubercle  bacillus 

Acute  adenitis — treatment :  In  all  infectious  diseases  care- 
ful and  frequent  cleansing  of  the  mouth,  and  nose,  and  naso- 
pharynx will  prevent  infection  of  the  glands. 

If  adenitis  has  begun,  search  the  drained  area,  and  treat 
any  inflammation  or  abrasion  there.  Wash  the  mouth,  nose, 
and  naso-pharynx  with  some  alkaline  solution  ;  syringe  the 
ear,  care  for  skin-diseases,  and  so  on.  Apply  cold  to  the  in- 
flamed gland  to  retard  the  inflammatory  process,  or  heat  if 
suppuration  seems  inevitable.  As  soon  as  softening  occurs 
lance  the  abscess,  as  thus  a  smaller  scar  is  left  than  when  it 
is  allowed  to  burst  itself.  In  cases  going  on  to  resolution 
daily  applications  of  a  10  to  20  per  cent,  ichthyol  ointment 
seem  to  assist  the  process. 

CHRONIC  ADENITIS. 

Definition:  In  this  condition  it  is  understood  that  the 
glands  arc  in  a  state  of  chronic  inflammation  of  a  simple 
character,  thai   is,  neither  tubercular  Dor  syphilitic. 


308  DISEASES  OF  THE  LYMPH-NODES. 

Etiology :  This  is  also  fairly  common  in  children.  It  often 
remains  after  an  attack  of  acute  adenitis ;  but  usually  is  the 
result  of  chronic  inflammations  of  the  skin  or  mucous  mem- 
branes in  the  region  drained.  Some  children  seem  especially 
prone  to  such  conditions. 

Pathology :  The  glands  undergo  a  true  hyperplasia,  with 
an  increase  of  both  their  cellular  and  connective-tissue  ele- 
ments.    The  latter,  however,  are  usually  in  excess. 

Chronic  adenitis — symptoms  :  The  only  symptom  is  the  en- 
largement of  the  glands.  This  is  usually  moderate  in 
amount,  and  tenderness  and  other  signs  of  acute  inflamma- 
tion are  absent.  There  is  very  little  tendency  for  the  glands 
to  increase  in  size,  and  softening  and  suppuration  are  almost 
unknown.  More  than  one  group  is  usually  involved,  and 
hypertrophied  tonsils  and  adenoids  are  apt  to  be  present  in 
the  same  case. 

Diagnosis :  The  important  point  is  to  be  able  to  exclude 
tubercular  and  syphilitic  enlargements  of  the  glands.  The 
finding  of  a  local  cause  of  irritation  is  of  main  value.  Sim- 
ple enlargement  occurs  in  younger  children,  and  shows  no 
tendency  to  involve  contiguous  tissues  nor  to  suppurate.  A 
gland  enlarged  from  a  simple  inflammation  may  later  become 
tubercular.     The  diagnosis  in  many  cases  is  very  difficult. 

Prognosis :  This  is  very  good,  as  the  curing  of  the  cause 
usually  hastens  absorption  of  the  inflammation. 

Chronic  adenitis — treatment :  Hunt  carefully  over  the 
drained  area  for  the  cause  of  the  inflammation,  and  treat  it. 
If  diseases  of  the  scalp,  or  discharges  from  the  ear,  or  ade- 
noids, or  naso-pharyngitis  are  present,  treat  them  as  usual. 
Improve  the  child's  health  in  every  way  by  iron,  cod-liver 
oil,  nourishing  diet,  and  fresh  air.  Locally,  applications  of 
iodine  or  of  ichthyol  may  hasten  absorption,  and  can  do  no 
harm. 

TUBERCULAR  ADENITIS. 

This  common  condition,  before  the  knowledge  of  the 
tubercle  bacillus,  was  called  scrofula. 

Etiology :  The  lymphatic  system  seems  particularly  prone 
to  tuberculosis,  and  this  condition  is  seen  oftenest  in  children 


TUBERCULAR  ADENITIS.  309 

over  three  years  old.  Those  with  a  tubercular  family  history 
are  specially  subject  to  it.  At  the  same  time,  with  this  pre- 
disposition there  is  usually  present  some  local  irritant,  as 
chronic  inflammation  of  the  skin  or  mucous  membranes  in 
the  drained  area.  Other  cases  follow  attacks  of  one  or  other 
of  the  infectious  diseases.  In  addition  to  these  causes  there 
is  always  present  infection  by  the  tubercle  bacillus.  The 
pharynx  seems  the  usual  place  of  infection,  as  the  cervical 
glands  are  those  oftenest  involved. 

Pathology  :  The  glands  are  swollen  and  the  seat  of  a  simple 
and  tubercular  inflammation  at  the  same  time.  The  cellular 
and  connective-tissue  elements  are  both  increased,  and  the 
gland  studded  more  or  less  thickly  with  miliary  tubercles 
and  tubercular  masses.  In  the  older  cases  these  tubercular 
masses  undergo  a  caseous  degeneration,  and  break  down  into 
tubercular  abscesses.  The  surrounding  tissues  first  become 
adherent  to  the  inflamed  glands,  and  later  are  involved  in 
the  same  inflammatory  process.  Neighboring  glands  be- 
come likewise  fused  together  into  one  mass.  Tubercular 
lesions  may  or  may  not  be  found  in  other  organs  of  the  body. 
Tubercle  bacilli  are  present  in  the  glands  in  moderate 
numbers. 

Tubercular  adenitis — symptoms  :  There  is  a  slowly  growing 
enlargement  of  one  or  more  groups  of  glands.  Those  of  the 
neck  are  most  often  affected ;  those  in  the  axilla  or  groin  less 
often.  Groups  in  two  or  more  places  may  be  involved  coin- 
cidently.  The  increase  in  size  continues,  and  fusing  of  the 
separate  glands  occurs  until  a  large  mass  is  present  in  which 
the  original  outlines  of  the  glands  cannot  be  made  out. 
Then  the  surrounding  tissues  become  adherent  to  the  mass 
and  likewise  involved.  By  this  time  areas  of  softening  occur 
which  approach  the  surface,  the  skin  becomes  discolored,  and 
an  abscess  bursts  externally,  discharging  thick,  curdy  pus 
with  bacilli.  Throughout  there  are  very  seldom  any  pain  or 
tenderness  of  the  inflamed  glands,  or  any  signs  other  than 
those  of  their  presence. 

The  process  usually  extends  over  many  months  or  years 
from  the  first  appearance  of  enlargement  to  the  time  of  sup- 
puration.     The  general  health  may  be  somewhat  depreciated, 


310  DISEASES  OF  THE  LYMPH-NODES. 

the  child  becoming  anaemic  and  poorly  nourished.  After 
bursting,  the  discharge  may  continue  for  an  indefinite  length 
of  time  with  a  permanent  sinus,  or  may  stop  and  healing 
occur.  Under  any  circumstance,  irregular,  large  disfiguring 
scars  are  left. 

Diagnosis :  The  diagnostic  points  are  the  tendency  to  con- 
glomeration of  the  glands,  their  caseation,  and  the  character 
of  the  discharged  pus  in  which  tubercle  bacilli  may  be  found. 
The  child's  family  history  is  also  an  aid.  The  enlarged  glands 
of  simple  chronic  adenitis,  or  of  Hodgkin's  disease,  do  not 
suppurate.  Syphilitic  enlargement  usually  has  the  history  to 
help  us.  The  difficulty  of  diagnosis  is  great  in  the  early 
stages. 

Prognosis  :  Most  of  these  cases  get  well ;  some  after  many 
years  of  discharging  sinuses.  A  very  few  develop  tubercu- 
losis elsewhere  and  die  of  this  condition. 

Tubercular  adenitis — treatment :  The  main  points  in  treat- 
ment are  the  cure  of  local  conditions  in  the  skin,  nose,  throat, 
or  elsewhere  that  originally  caused  the  glands  to  enlarge. 
After  this  everything  should  be  directed  to  the  general  health 
of  the  child — fresh  air,  exercise,  nourishing  diet,  and  change 
of  climate  if  possible.  Internally,  iron,  arsenic,  and  cod- 
liver  oil  are  very  helpful.  The  former  is  best  given  as  the 
syrup  of  the  iodide. 

If,  after  some  months  of  this  treatment,  no  impiovement 
is  seen,  and  particularly  if  suppuration  threatens,  the  case 
should  be  put  under  surgical  care.  Operation,  if  undertaken, 
should  be  thorough,  and  the  scars  left  by  this  are  far  less  dis- 
figuring than  those  after  spontaneous  evacuation. 


CHAPTER   XIII. 

DISEASES  OF  THE  SKIN. 

LENTIGO. 

The  common  name  for  this  affection  is  freckles.  It  con- 
sists of  small  pigmented  spots,  occurring  in  groups  on  sur- 
faces that  are  ordinarily  left  uncovered. 

Etiology  :  It  occurs  oftenest  in  children  over  five  years  old, 
and  in  blondes  with  a  tendency  to  red  hair.  There  seems 
some  connection  between  it  and  exposure  to  sunlight. 

Lentigo — treatment :  Apply  a  1  per  cent,  solution  of  cor- 
rosive sublimate  on  a  piece  of  lint  to  the  aifected  region  for 
three  or  four  hours.  This  raises  a  blister,  which  should  be 
pricked  and  dressed  with  dry  powder.  When  the  raised  skin 
desquamates  the  new  epidermis  is  free  from  pigment.  The 
treatment  is  somewhat  painful. 

ICHTHYOSIS. 

This  is  a  congenital  deformity  of  the  skin  characterized  by 
the  formation  all  over  the  surface  of  dry  scales,  and  with  a 
lack  of  the  normal  cutaneous  secretions. 

Etiology :  The  only  point  known  is  that  the  disease  occurs 
in  families. 

Pathology  :  It  consists  in  an  excessive  growth  of  the  epi- 
dermal cells. 

Ichthyosis — symptoms  :  The  dry,  scaly  condition  of  the  skin 
is  the  only  symptom.  These  scales  desquamate  freely,  and 
long  crack-  form  through  the  skin  at  flexures,  which  may  be 
painful.  Perspiration  is  absent.  The  sense  of  touch  is  much 
interfered  with.  Except  in  the  very  worst  cases  the  disease  is 
not  dangerous.  These  children  are  frequently  exhibited  as 
freaks,  being  called  fish-  or  alligator-boys. 

311 


312  DISEASES  OF  THE  SKIN. 

Prognosis :  The  condition  is  incurable,  but  is  ordinarily 
compatible  with  long  life. 

Ichthyosis — treatment :  Internally,  the  use  of  the  fatty 
foods  is  to  be  recommended. 

Locally,  daily  warm  baths  should  be  taken,  with  plenty  of 
soap  to  remove  the  loose  scales,  and  then  the  whole  skin 
should  be  thoroughly  rubbed  with  lanoline  or  vaseline,  to 
keep  it  as  soft  and  pliable  as  possible. 

SEBORRHEA. 

This  condition  of  thick,  dry  crust-formation,  is  very  com- 
mon on  the  heads  of  infants. 

Etiology :  It  is  caused  by  an  excessive  production  of  the 
secretions  of  the  sebaceous  glands,  which  are  allowed  to  dry 
on  the  scalp  and  become  mixed  with  dirt. 

Seborrhoea — symptoms :  The  vertex  of  the  head  presents  a 
large  patch  of  dirty,  yellowish,  greasy  secretion.  On  exami- 
nation it  is  found  to  consist  of  epithelial  cells,  granular  mat- 
ter, fat,  and  dirt.  The  skin  under  it  is  ordinarily  normal  and 
shows  no  signs  of  inflammation. 

Seborrhoea — treatment :  Keep  a  vaseline  poultice  on  the 
scalp  over  night,  held  in  place  by  a  nightcap  or  a  bandage. 
Next  morning  the  free  use  of  warm  water  and  soap  will  re- 
move most  of  the  crusts  easily.  Repeat  this  successive  nights 
until  the  condition  is  gone.  Afterward  apply  daily  an  oint- 
ment containing  10  grains  of  resorcin  to  the  ounce  of  vaseline. 

MILIARIA. 

This  is  commonly  called  prickly  heat,  and  is  a  very  common 
condition  in  childhood. 

Etiology :  It  is  regularly  caused  by  intense  heat,  with  ex- 
cessive production  of  irritating  perspiration. 

Pathology :  This  is  an  acute  inflammation  of  the  sweat- 
glands,  resulting  in  damming  up  of  the  minute  ducts  and  the 
formation  of  small  papules  with  minute  vesicles  on  their  sum- 
mits. 

When  the  inflammation  is  very  slight  it  is  called  sudamina, 
and  consists  of  the  minute  vesicles  only. 


FUR  UNCULOSIS.  3 1 3 

Miliaria — symptoms  :  The  symptoms  are  this  widely  spread 
red  rash,  consisting  of  the  minute  vesiculated  papules,  which 
may  become  infected  and  turn  into  pustules,  associated  with 
intense  smarting  and  burning.  It  is  usually  most  marked  on 
the  trunk  and  head,  but  may  be  universal. 

Diagnosis  :  This  is  easy.  A  careful  inspection  of  the  rash, 
the  history  of  the  case,  and  the  state  of  the  atmospheric  tem- 
perature are  the  points  for  consideration. 

Miliaria — treatment :  During  hot  weather  the  child  should 
be  lightly  dressed,  with  cotton  next  the  skin,  should  be  fre- 
quently bathed  in  cold  water,  and  the  skin  kept  dusted  with 
some  dry  non-irritating  powder,  such  as  the  stearate  of 
zinc,  which  acts  very  nicely. 

If  the  eruption  is  present,  these  measures  should  be  con- 
tinued ;  and,  in  addition,  the  bowels  should  be  opened,  the 
diet  should  be  light,  and  internally  some  mild  diuretic,  such 
as  sweet  spirits  of  nitre,  given.  The  zinc  and  calamine  lo- 
tion— zinc  oxide,  sss  ;  pulv.  calamine,  3ij  ;  glycerin,  |j  ; 
liquor  calcis,  ad  gviij — should  be  applied  freely.  One  per 
cent,  of  carbolic  acid  may  be  added,  if  there  is  any  tendency 
to  infection.  Under  this  treatment  the  case  should  recover 
in  a  few  days. 

FURUNCULOSIS. 

A  boil  is  an  intense  localized  inflammation  occurring  about 
a  hair-follicle  or  a  gland  of  the  skin. 

Etiology :  Boils  are  probably  due  to  a  direct  infection  of 
the  follicle  by  micro-organisms.  Pus  from  one  boil  will  in- 
fect another  follicle,  and  in  this  way  successive  crops  are 
formed.  Local  injury  of  a  slight  nature  often  opens  the  way 
for  infection. 

Boils  are  fairly  common  in  children,  but  never  seem  so 
deep-seated,  indurated,  and  painful  as  they  heroine  in  adults. 

Furunculosis — symptoms:  A  boil  begins  as  a  small  red 
papule,  but  the  surrounding  skin  rapidly  becomes  indurated 
and  lender.  A  small  whitish  top  soon  forms  over  it,  but  on 
removing  this  no  pus  escapes.  The  pain  is  severe  and  throb- 
bing, and   the  neighboring  Lymphatics  may  become  inflamed 


314  DISEASES  OF  THE  SKIN. 

and  tender.  There  may  be  some  constitutional  symptoms  in 
the  worst  cases. 

After  a  week  or  ten  days  pus  collects  in  considerable  quan- 
tity in  the  boil,  and  on  evacuating  it  the  centre  of  the  boil 
shows  the  presence  of  a  large  white  necrotic  mass — the  core. 
This  core  is  the  remnant  of  the  dead  follicle  or  gland.  After 
its  removal  a  little  cavity  is  left  to  fill  by  granulation,  and 
with  this  the  parts  soften  and  the  pain  and  tenderness  disap- 
pear. 

Diagnosis :  There  is  no  reason  for  confusing  this  condition 
with  any  disease. 

Furunculosis — treatment :  Improve  the  general  health  by 
the  use  of  arsenic  and  the  hypophosphites.  When  a  boil  is 
beginning  put  over  it  a  wet  dressing  of  carbolic  acid  in  2 
per  cent,  solution.  As  soon  as  it  begins  to  point  incise  freely 
and  continue  this  wet  carbolic  dressing.  By  this  means  we 
rapidly  heal  up  any  boil  present  and  prevent  the  formation 
of  others.  Very  careful  cleaning  of  the  skin,  and  subsequent 
applications  of  1  :  1000  bichloride  of  mercury,  or  of  1  :  40 
carbolic  acid,  will  prevent  the  formation  of  additional  boils. 

IMPETIGO  CONTAGIOSA. 

This  is  an  infectious  disease  of  the  skin  characterized  by 
the  formation  of  vesicles  and  pustules. 

Etiology :  The  disease  occurs  almost  always  in  children,  is 
contagious,  and  hence  is  seen  oftenest  in  a  number  of  children 
in  the  same  family,  or  among  the  poor,  living  in  the  same 
tenements.  Probably  some  as  yet  unknown  form  of  bacterial 
infection  is  the  actual  cause. 

Impetigo  contagiosa — symptoms :  There  are  often  a  little 
fever  and  malaise  with  'the  outbreak  of  the  eruption.  This 
begins  as  isolated  vesicles,  the  contents  of  which  soon  become 
pustular,  and  then  a  dry,  yellowish  scab  forms  on  the  surface. 
After  this  crust  drops  the  surface  is  red,  but  no  depression  is 
left.  The  eruption  is  usually  confined  to  the  hands  and  face. 
The  lesions  may  remain  discrete  or  may  coalesce,  and  usually 
heal  in  a  couple  of  weeks.  Fresh  crops  from  auto-inocula- 
tion may  prolong  the  attack  indefinitely. 


ECZEMA.  315 

Diagnosis  :  Pemphigus  and  chickenpox  are  most  apt  to  be 
confused.  The  points  are  the  distribution  of  the  lesions, 
their  contagious  character,  and  the  isolated  vesico-pustules. 

Prognosis  is  very  good. 

Treatment :  Remove  the  crusts,  wash  the  parts  carefully, 
and  apply  an  antiseptic  ointment,  as  unguentum  hydrargyri 
ammoniati. 

ECZEMA. 

Definition :  This  very  common  skin  disease  of  infancy  and 
childhood  is  a  dermatitis,  characterized  by  itching,  redness, 
infiltration,  moisture,  and  crusting.  It  may  be  acute  or 
chronic,  and  presents  a  boundless  variety  of  lesions. 

Etiology :  While  the  disease  is  especially  frequent  in  child- 
hood, it  presents  no  essential  differences  from  the  eczema  of 
adult  life.  The  skin  in  most  children  is  very  susceptible  to 
irritation  both  from  outside  and  inside,  but  in  certain  ones 
there  seems  to  exist  an  especial  predisposition  to  inflammatory 
action.  This  tendency  is  at  times  inherited.  The  parents 
are  often  subjects  of  a  gouty  or  rheumatic  diathesis.  Chil- 
dren brought  up  amid  unhygienic  surroundings,  being  im- 
properly nourished  and  unaccustomed  to  good  air,  are  often 
the  subjects  of  eczema.  On  the  other  hand,  very  frequent 
examples  of  the  disease  are  seen  in  children  seemingly  in  the 
best  of  health,  with  their  nutrition  above  the  normal,  and 
their  skin  pink  and  healthy.  These  latter  seem  especially 
prone  to  facial  eczema. 

The  exciting  causes  acting  from  within  the  organism  are 
oftenest  connected  with  digestion  and  elimination.  It  is  seen 
in  both  breast-  and  bottle-fed  babies,  but  more  often  in  the 
latter  because  they  are  oftenest  the  subjects  of  digestive  de- 
rangements. Indigestion  from  over-feeding,  from  excessively 
high  percentages  of  fat,  or  proteids,  or  sugar  in  the  milk,  or 
from  ton  early  use  of  starch,  is  a  frequent  cause.  On  the 
oilier  hand,  mother's  milk  or  artificial  food  in  which  the 
nutritive  value  is  far  below  normal  may  be  responsible. 
Improper  articles  of  diet  for  the  age  of  the  child  are  often 
causative  ;  as  are  also  constipation  and  deficient  action  of  the 
Liver  or  kidneys. 


316  DISEASES  OF  THE  SKIN. 

Reflex  irritation,  acting  through  the  nervous  system,  un- 
doubtedly may  be  a  partial  cause  at  least  of  certain  cases,  as 
in  dentition. 

External  irritants  which  may  cause  an  outbreak  are  cold, 
heat,  irritating  soap,  powders,  excessive  bathing,  and  clothing 
of  a  rough  texture.  Discharges  from  the  nose,  ear,  eyes, 
genitals,  or  rectum,  and  wet  diapers  will  frequently  start  the 
disease.  Parasites,  as  pediculi,  acari,  and  trichophyta,  will 
produce  it.  In  most  cases  there  is  more  than  one  cause 
acting.     The  disease  is  not  contagious. 

Eczema — symptoms :  In  infants  eczema  is  more  often  seen 
about  the  head  and  face  than  elsewhere.  Any  of  the  various 
lesions — erythema,  papules,  vesicles,  or  pustules — may  be  pres- 
sent  singly  or  combined  in  the  individual  case.  There  is 
always  intense  itching,  and  the  child's  scratching  adds 
mechanical  lesions  to  those  of  the  original  inflammation.  The 
inflamed  surface  discharges  a  serous  secretion  which  dries  on 
the  skin  and  forms  yellow  crusts.  Scratching  these  causes 
bleeding,  so  that  many  of  them  become  dark  brown.  Many 
of  the  lesions  become  infected,  and  the  eczema  then  takes  on 
the  pustular  form.  This  pustular  variety  is  most  frequent  in 
the  scalp.  Each  variety  has  its  own  particular  name,  but 
there  is  no  special  advantage  in  these  subdivisions. 

The  lesions  spread  usually  from  one  neighborhood  to 
another,  until  finally  a  large  portion  of  the  skin  becomes 
involved.  It  is  quite  common  for  the  lymphatic  glands  to  be 
inflamed,  and  to  swell,  and  even  to  form  abscesses. 

In  the  groin,  and  other  regions  where  two  surfaces  of  skin 
come  into  close  contact,  intertrigo  or  erythematous  eczema 
develops  quite  regularly. 

All  varieties  of  eczema  are  subject  to  frequent  relapse,  and 
all  require  great  care  and  perseverance  in  treatment. 

The  reader  is  referred  to  special  books  on  the  subject  for 
more  detailed  description  as  to  lesions. 

Diagnosis :  Scabies  and  syphilis  cause  lesions  most  likely  to 
be  confused  with  eczema.  Remember  the  characteristics  of 
eczema  :  multiform  lesions,  serous  discharge  or  "  weeping," 
crusting,  and  itching.  Scabies  itches  badly,  but  is  usually 
found  in  other  members  of  the  family,  and  on  special  locali- 


ECZEMA.  317 

ties,  as  the  webs  of  the  fingers,  the  flexures  of  the  wrists  and 
elbows,  and  around  the  genitals.  With  care  the  burrows  of  the 
acarus  may  usually  be  found.  Syphilis  gives  multiform 
lesions,  but  does  not  itch.  The  eruption  is  dark  colored  and 
the  child  usually  shows  general  cachexia. 

Prognosis  :  It  is  a  slow,  tedious  disease.  With  proper  care 
most  cases  can  be  cured  ;  but  relapses  are  common,  and  the 
patience  of  the  physician  and  of  the  family  will  be  tried  to 
the  utmost  in  the  meantime. 

Eczema — treatment :  Search  into  every  possible  external, 
internal,  and  reflex  cause  of  the  condition  ;  if  anything  is 
found  wrong,  correct  it,  and  regulate  the  child's  life  accord- 
ing to  the  most  approved  hygienic  rules.  This  means  special 
attention  to  the  condition  of  the  stomach,  intestines,  liver, 
and  kidneys.  The  most  painstaking  care  should  be  taken  in 
these  lines,  and  no  little  thing  must  be  neglected.  Intelli- 
gent co-operation  on  the  part  of  the  mother  and  nurse  is  very 
important.  All  local  irritants  must  be  removed,  and  irritat- 
ing discharges  cured.  Water  should  not  be  applied  to  eczem- 
atous  surfaces.  It  has  a  specially  irritating  effect  on  them. 
A  bland  oil  may  be  used  for  purposes  of  cleanliness,  and  the 
parts  mopped  dry  afterward.  Prevent  scratching,  if  neces- 
sary, by  confining  the  child's  hands. 

During  the  acute  stage  some  soothing  ointment  should  be 
applied  and  kept  in  place  by  a  bandage  or  mask.  The  plain 
oxide  of  zinc  ointment,  or  this  with  1  per  cent,  of  carbolic 
acid  added  to  allay  the  itching,  answers  the  purpose  well.  In 
the  more  subacute  cases  a  stimulating  ointment,  as  one  con- 
taining tar  in  some  form,  is  of  most  value.  Another  useful 
formula  is  Lassar's  paste,  with  ten  grains  of  salicylic  acid  to 
the  ounce  of  ointment. 

In  the  various  text-books  on  dermatology  will  be  found  in- 
numerable form  like  for  the  different  stages.  Here  it  is  nee- 
essary  to  emphasize  principles  only  :  remove  causes,  prevent 
washing  and  scratching,  apply  soothing  remedies  to  acute 
cases,  and  stimulating  ones  to  chronic  eases.  All  applica- 
tions should  be  kept  persistently  in  contact  with  the  inflamed 
skin. 


318  DISEASES  OF  THE  SKIN. 

URTICARIA. 

This  is  also  called  hives  and  nettle-rash.  It  consists  of 
suddenly  appearing,  elevated,  irregularly  shaped  blotches  in 
the  skin,  called  wheals.  They  are  usually  paler  than  the  sur- 
rounding skin,  but  may  be  pink.  They  disappear  equally 
quickly,  and  leave  no  trace  behind. 

Etiology :  Local  irritants,  such  as  coarse  underclothing, 
bites  of  insects,  and  some  vegetable  poisons,  will  produce  the 
wheals.  A  large  number  are  due  to  gastro-intestinal  irrita- 
tion, as  indigestion  from  any  source ;  but  certain  special  arti- 
cles of  diet  always  produce  attacks  in  certain  individuals. 
Strawberries,  fish-food,  and  oatmeal  are  among  such  articles. 
Certain  drugs,  as  quinine,  will  sometimes  cause  it. 

Urticaria — symptoms :  The  wheals  are  quite  characteristic 
in  their  onset,  appearance,  and  manner  of  disappearing. 
They  itch  intensely,  and  scratching  will  often  develop  new 
crops.  As  the  attack  begins  some  fever  may  accompany  it, 
with  general  malaise.  No  other  skin  disease  has  any  special 
resemblance  to  it. 

Prognosis :  This  is  perfectly  good,  but  individuals  who 
once  have  the  disease  are  very  apt  to  have  subsequent  at- 
tacks. 

Urticaria — treatment :  Find  the  cause,  if  possible,  and  re- 
move it.  All  local  irritants  should  be  taken  away.  As  the 
digestive  system  is  so  frequently  at  fault,  it  is  always  well  to 
clean  it  out  thoroughly  at  once.  This  is  best  done  by  a  dose 
of  a  saline  cathartic.     After  this  regulate  the  diet. 

Locally,  an  alkaline  bath  is  always  good  to  allay  the  itch- 
ing, or  a  solution  of  menthol,  gr.  x  to  the  ounce.  Nothing 
further  is  necessary  except  so  to  regulate  the  food  and  cloth- 
ing as  to  prevent  subsequent  attacks. 

SCABIES. 

This  disease  is  called  commonly  the  itch.  It  is  not  very 
frequent  in  this  country. 

Etiology :  It  is  due  to  the  boring  under  the  skin  of  the 
female  acarus  scabiei  for  the  purpose  of  laying  her  eggs. 
The  male  parasite  remains  on  the  surface.     The  little  furrow 


TINEA    TRICHOPHYTINA.  319 

made  by  the  acarus  is  a  pigmented,  irregular  line,  which  is 
the  characteristic  diagnostic  point  of  the  disease.  At  the  ex- 
tremity of  the  burrow  the  minute  insect  will  usually  be 
found. 

Pathology :  Around  the  itch-mite  in  the  burrow  will  be  a 
zone  of  inflammation,  which  is  either  a  papule,  a  vesicle,  or 
a  pustule.  In  fact,  the  lesions  of  scabies  are  quite  multi- 
form. 

Scabies — symptoms  :  The  acarus  chooses  places  to  burrow 
where  the  skin  is  thin,  and  hence  the  lesions  are  found  most 
frequently  in  the  webs  of  the  fingers,  on  the  folds  of  the 
wrists,  about  the  breasts  and  genitals.  The  burrows,  to- 
gether with  the  multiform  lesions  and  the  intense  itching,  are 
the  main  symptoms.  To  relieve  the  itching  the  scratching 
is  incessant,  and  the  mechanical  lesions  of  this  are  added. 
This  probably  explains  the  frequent  presence  of  lesions  about 
the  genitals.  In  infants  the  face  may  be  involved  from  in- 
fection from  its  mother's  breast. 

Diagnosis:  From  simple  eczema  the  finding  of  the  burrow 
and  the  acarus  decides  the  diagnosis. 

Prognosis  :  This  is  good.     Cure  is  comparatively  easy. 

Scabies — treatment :  The  child  should  first  be  given  a  soap 
and  hot-water  bath,  the  soap  being  very  thoroughly  applied 
in  regions  where  lesions  are  found.  After  this  a  sulphur 
ointment  should  be  well  rubbed  in  over  all  the  affected  parts. 
This  should  be  repeated  two  or  three  times,  and  until  the 
acari  are  killed.  All  clothes  and  night-dresses  should  be 
sterilized  by  boiling. 

TINEA  TRICHOPHYTINA. 

This  is  commonly  called  ring-worm,  and  is  frequently  seen 
iu  children  on  the  skin,  general  surface,  or  scalp. 

Etiology:  This  disease  Is  due  to  the  growth  in  the  skin  of 
the  trichophyton  fungus.  It  is  a  vegetable  parasite  consisting 
of  mycelial  threads  and  spores. 

Tinea  trichophytina — symptoms:  The  disease  begins  as  a 
slightly  red  scaling  spot.  If  in  the  scalp,  the  hairs  in  this 
spot  become   broken   oil'  and    point    in   all    directions.     The 


320  DISEASES  OF  THE  SKIN. 

infection  spreads  from  this  point  in  a  circle,  the  centre  begins 
to  heal,  and  eventually  by  this  process  of  peripheral  spread- 
ing and  central  healing,  a  ring  is  produced,  which  gives  the 
name  to  the  disease.  Two  or  more  points  may  be  infected  at 
the  same  time,  and  the  rings  formed  from  each  may  cut  into 
one  another,  forming  irregular  figures. 

In  the  scalp,  a  common  location  in  children,  the  hairs 
become  brittle,  lose  their  lustre,  and  give  quite  a  "  moth- 
eaten  "  appearance  to  the  aifected  area.  Often  ring- worm  in 
the  scalp  gets  infected,  and  pustules  form  in  the  hair-follicles. 
If  such  a  case  becomes  chronic,  we  get  the  condition  known 
as  kerion,  where  the  whole  area  becomes  boggy  from  the 
infection.  The  disease  does  not  produce  much  itching  nor  any 
other  subjective  symptoms. 

Diagnosis :  Syphilis,  eczema,  and  psoriasis  all  may  form 
circinate  figures,  but  by  taking  the  other  lesions  into  consider- 
ation usually  no  error  need  be  made.  By  microscopical 
examination  of  scrapings  taken. from  the  lesions  the  fungus 
may  be  easily  found. 

Prognosis  :  In  the  skin  it  is  easy  to  cure.  In  hairy  areas  it 
is  more  difficult,  but  perseverance  brings  it  to  an  end  here 
also. 

Tinea  trichophytina — treatment :  On  the  skin  daily  appli- 
cations of  tincture  of  iodine  will  cure  the  case  rapidly. 

In  the  scalp  the  hair  should  be  clipped  close,  and  the 
lesions  thoroughly  cleaned  with  soap  and  hot  water.  After 
this  an  ointment  of  white  precipitate  should  be  rubbed 
thoroughly  into  the  aifected  regions.  This  treatment,  cleans- 
ing and  anointing  daily,  should  be  continued  till  all  signs  of 
the  disease  are  gone.  There  are  many  valuable  ointments,  for 
which  reference  should  be  made  to  the  special  text-books.  In 
the  very  persistent  chronic  cases  epilation  may  be  necessary. 


CHAPTER    XIV. 

DISEASES   OF   THE   EAR. 

ACUTE  OTITIS. 

Inflammations  of  the  middle  ear  are  excessively  common  in 
infancy  and  childhood. 

Etiology :  It  is  usually  secondary  to  inflammation  in  the 
naso-pharynx,  such  as  cold  in  the  head,  adenoids,  enlarged 
tonsils,  and  pharyngitis  complicating  the  infectious  diseases. 
The  commonest  of  these  are  scarlet  fever  and  influenza.  It 
may  occur  after  measles,  diphtheria,  or  typhoid.  Picking  at 
the  ears,  foreign  bodies  in  the  ears,  and  boxing  the  ears  are 
also  causes. 

Pathology :  The  inflammation  in  the  pharynx  spreads 
through  the  Eustachian  tube,  swelling  the  mucous  membrane 
and  causing  an  increased  secretion  of  mucus,  which  may 
become  purulent.  This  inflammation  may  be  confined  to  the 
mucous  membrane  of  the  Eustachian  tube,  or  may  spread  to 
that  lining  the  middle  ear.  In  the  middle  ear  the  inflam- 
mation may  be  the  milder  catarrhal  variety,  or  the  more 
severe  purulent  form  with  the  presence  of  the  germs  of  sup- 
puration. 

Acute  otitis — symptoms :  Following  the  symptoms  of  the 
primary  disease,  the  child  has  the  two  symptoms  of  otitis: 
fever  and  pain.  The  fever  may  be  only  100°  F.  ;  or  may  be 
much  higher,  reaching  often  104°  F.  The  pain,  or  earache, 
is  quite  a  prominent  sign,  and  the  one  that  leads  us  to  sus- 
pect the  ear  as  the  cause  of  the  fever.  The  pain  is  acute  and 
severe,  and  in  young  infants  who  cannot  talk  is  evidenced  by 
restlessness,  crying,  and  tenderness  on  pressure  about  the  ear. 
The  crying  from  earache  is  apt  to  be  incessant  and  con- 
tinuous. In  infant-  eases  do  occur,  however,  in  which  the 
pain  and  tenderness  seem  very  slight.  With  the  fever  there 
21— D.  c.  321 


322  DISEASES   OF  THE  EAR. 

are  general  malaise,  anorexia,  headache,  and  constipation. 
The  symptoms  last  a  day  or  two  to  a  week,  and  gradually 
cease  with  the  subsidence  of  the  inflammation ;  or  more 
quickly  in  case  the  otitis  leads  to  rupture  of  the  drumhead, 
with  free  exit  to  the  inflammatory  exudate.  In  the  latter 
case  the  discharge  from  the  ear  is  rather  profuse  at  first,  but 
gradually  becomes  less  in  quantity,  and  finally  ceases  with 
healing  of  the  rent  in  the  membrane. 

In  the  purulent  variety  mastoid  abscess,  thrombosis  of  the 
lateral  sinus,  meningitis,  or  cerebral  abscess  may  develop 
from  extension  of  the  inflammation  to  these  parts. 

Diagnosis :  Fever  of  unknown  origin,  combined  with  pain  or 
evidences  of  tenderness  about  the  ear,  is  usually  sufficient 
for  diagnosis.  Infants  who  have  long  crying  attacks  are  very 
apt  to  be  suffering  from  earache.  If  possible,  an  examination 
of  the  ear  should  be  made  through  a  speculum.  The  mem- 
brane will  be  found  red  and  congested,  and  bulging  if  secre- 
tions are  behind  it.  A  discharge  and  a  perforation  may  be 
found. 

Prognosis  :  In  the  catarrhal  form  the  prognosis  for  recovery 
without  impairment  of  hearing  is  good.  In  the  purulent 
form,  after  recovery  there  is  apt  to  be  either  partial  or  com- 
plete deafness  in  that  ear,  while  there  are  many  cases  of  serious 
disease,  and  even  of  death,  following  the  complications. 

Acute  otitis — treatment :  In  the  early  stages  the  local  appli- 
cation of  heat  by  a  hot-water  bag,  a  Japanese  stove,  or  by 
prolonged  douching  with  hot  water  by  a  fountain-syringe,  will 
relieve  the  pain  and  hurry  the  inflammation  through.  At 
the  same  time  touching  the  naso-pharynx  with  some  astrin- 
gent, as  silver  nitrate,  is  good.  The  bowels  should  be  opened 
by  broken  doses  of  calomel,  and  the  child  kept  in  a  warm 
room  with  an  equable  temperature.  If  the  pain  continues,  it 
is  justifiable  to  put  a  few  drops  of  a  solution  of  atropine,  1 
per  cent.,  and  cocaine,  4  per  cent.,  in  the  external  meatus. 
If  the  membrane  is  found  to  be  bulging  and  tense,  it  is  better 
to  perform  paracentesis  than  to  wait  for  the  membrane  to  rupt- 
ure spontaneously.  After  spontaneous  or  artificial  perfora- 
tion of  the  drum-membrane,  the  ear  must  be  kept  scrupu- 
lously clean  and  dry. 


CHRONIC  OTITIS.  323 


CHRONIC  OTITIS. 


This  means  really  a  chronic  otorrhoea. 

Etiology :  It  usually  follows  repeated  attacks  of  the  acute 
disease  in  delicate,  poorly  nourished  children.  It  often  is  due 
to  neglect  of  proper  treatment. 

Pathology  :  There  is  a  chronic  purulent  inflammation  in  the 
middle  ear,  with  rupture  or  destruction  of  the  drum-mem- 
brane, and  a  constant  purulent  discharge  from  the  external 
meatus. 

Chronic  otitis — symptoms :  The  main  symptom  is  the  dis- 
charge, which  is  often  quite  free  and  creamy,  and  is  apt  to 
have  a  very  characteristic,  disagreeable  odor.  This  discharge 
may  cause  eczematous  eruption  of  the  external  ear,  and  with 
it  may  be  associated  a  cervical  adenitis. 

Diagnosis  :  This  is  made  by  the  presence  of  the  chronic  dis- 
charge, and  the  examination  of  the  drum-membrane,  if  it 
can  be  performed. 

Prognosis :  While  these  cases  are  often  obstinate,  they  can 
usually  be  cured  by  perseverance. 

Chronic  otitis — treatment :  Excessive  cleanliness  of  the 
meatus,  syringing  twice  a  day  with  a  boracic  acid  solution, 
and  then  drying  the  parts  carefully,  will  usually  heal  them. 
Peroxide  of  hydrogen  has  a  useful  field  here.  At  the  same 
time  any  inflammatory  condition  in  the  naso-pharynx  should 
be  attended  to,  and  the  child's  general  health  brought  as  near 
normal  as  possible. 


CHAP  TEE    XV. 
DISEASES  OF  THE   BONES. 

ACUTE  ARTHRITIS. 

Definition :  This  is  a  suppurative  disease  of  the  extremities 
of  the  bones,  occurring  with  some  frequency  in  infancy.  It 
is  also  called  acute  epiphysitis. 

Etiology :  It  is  an  infection  of  the  extremity  of  the  bone 
by  pyogenic  organisms,  which  may  gain  entrance  through 
almost  any  lesion  of  the  skin  or  mucous  membrane.  Trau- 
matism of  the  joint  is  probably  a  partial  cause. 

Pathology  :  The  inflammation  usually  begins  at  the  epiphy- 
seal junction,  and  spreads  into  the  joint  and  to  the  shaft.  It 
is  really  an  osteomyelitis,  modified  by  the  anatomical  condi- 
tion of  the  epiphysis  in  infancy.  It  is  very  apt  to  go  on  to 
the  production  of  an  abscess  either  subperiosteally  or  in  the 
joint.  Secondary  abscesses  elsewhere  are  common,  when  the 
true  pysemic  nature  of  the  disease  becomes  apparent. 

Acute  arthritis — symptoms :  The  disease  begins  suddenly 
with  a  chill,  and  fever  of  a  remittent  type.  General  prostra- 
tion and  other  symptoms  of  fever  accompany  this.  The 
affected  joint  becomes  swollen,  red,  painful,  and  very  tender, 
so  much  so  as.  to  produce  a  voluntary  paresis.  If  pus  forms, 
signs  of  deep  fluctuation  are  present,  and  burrowing  may  be 
extensive  or  rupture  externally  may  take  place.  Death  may 
occur  from  the  intensity  of  the  infection  in  a  few  days ;  or 
resolution  may  take  place  with  a  gradual  disappearance  of 
the  symptoms  ;  or,  after  rupture  of  the  abscess,  recovery  with 
a  damaged  joint  may  occur. 

Diagnosis :  The  disease  is  most  likely  to  be  confused  with 
acute  rheumatism,  but  in  infancy  rheumatism  seldom  assumes 
such  marked  local  symptoms. 

324 


POTT'S  DISEASE.  325 

Prognosis :  Death  takes  place  in  about  10  per  cent,  of  the 
cases.     Very  few  recover  without  some  disability  of  the  joint. 

Acute  arthritis — treatment :  The  child's  nutrition  should  be 
well  kept  up,  and  alcoholic  stimulants  will  usually  be  neces- 
sary. Pain  should  be  relieved  by  drugs  and  by  local  appli- 
cations. As  soon  as  signs  of  suppuration  occur,  or  even 
earlier,  free  incision  with  drainage  should  be  used  and  the 
case  treated  on  surgical  principles. 

POTT'S  DISEASE. 

Definition  :  This  is  a  tubercular  inflammation  of  the  bodies 
of  two  or  more  of  the  vertebra?. 

Etiology :  The  tubercle  bacillus  seems  particularly  prone  to 
invade  the  bones  in  children  during  the  period  after  they 
learn  to  walk.  Previously  healthy  children,  with  no  tuber- 
cular family  history,  may  be  attacked;  but  it  is  much  more 
common  in  delicate  children  with  a  bad  heredity.  It  may  fol- 
low attacks  of  one  of  the  infectious  diseases,  but  is  usually 
the  primary  tubercular  focus.  Traumatism  is  often  ascribed 
as  a  cause,  but  simply  offers  a  locus  minoris  resistevtice  for 
attack  by  the  bacillus. 

Pathology :  The  bodies  of  the  vertebrae  are  gradually  in- 
vaded by  the  tuberculous  tissue,  which,  having  poor  vitality, 
breaks  down,  producing  caries  of  the  bone.  With  this  comes 
formation  of  tubercular  abscesses,  which  may  remain  local- 
ized at  the  spot,  or  may  burrow  and  appear  at  the  surface  at 
considerable  distances.  The  intervertebral  disks  are  de- 
stroyed by  the  same  process.  The  weight  of  the  body  above 
the  disease  causes  the  carious  vertebra?  to  yield,  with  the  pro- 
duction of  the  characteristic  deformities  of  the  disease.  If 
only  one  or  two  vertebra?  are  diseased,  the  bend  is  quite  an 
acute  angle  ;  if  more,  the  curve  is  more  general. 

The  meninges,  the  roots  of  the  spinal  nerves,  and  even  the 
cord  itself,  may  be  involved  by  the  inflammatory  process. 

Pott's  disease — symptoms:  The  disease  begins  very  gradu- 
ally. The  child  seems  out-of-sorts,  tires  easily,  is  stiff  in  his 
movements,  and  has  restless  nights.  The  first  definite  symp- 
tom is  pain,  which   is  more  often   referred  to  the  abdomen 


326  DISEASES  OF  THE  BONES. 

than  to  the  back.  This  is  probably  due  to  irritation  of  the 
nerve-roots,  and  the  case  is  often  treated  for  indigestion. 
Later,  there  are  noticed  a  rigidity  of  the  spine  and  the  vol- 
untary assumption  of  certain  postures  which  relieve  the  pain. 
About  this  time  a  beginning  deformity  of  the  spine  at  the 
seat  of  the  lesion  may  be  noted,  or  in  others  paralysis  from 
pressure  on  the  cord.  Later  yet,  abscesses  form  and  remain 
localized  at  the  seat  of  trouble,  or  burrow  and  burst  at  remote 
points. 

The  general  health  may  remain  fairly  good  ;  but  usually  the 
child  becomes  anaemic,  emaciated,  and  feeble. 

The  disease  may  attack  the  cervical,  dorsal,  or  lumbar 
spine,  giving  localized  symptoms  according  to  the  region  in- 
volved. The  dorsal  vertebrae,  however,  are  attacked  much 
oftener  than  the  others.  The  deformity  produced  is  an 
antero-posterior  bending,  or  kyphosis.  Lateral  curves  are 
rare.  Abscesses  in  the  cervical  region  point  in  the  pharynx ; 
those  in  the  lower  dorsal  and  lumbar  travel  down  the  sheath 
of  the  psoas  muscle  and  point  in  the  groin. 

The  course  of  the  disease  is  essentially  chronic,  lasting  over 
a  number  of  years,  and  death  may  take  place  from  exhaus- 
tion, or  from  the  development  of  tuberculosis  elsewhere.  In 
the  cases  going  on  to  recovery  the  inflammatory  process 
ceases,  new  bone  is  deposited  in  the  carious  vertebra?,  and 
ankylosis  with  permanent  deformity  takes  place. 

Diagnosis :  This  is  made  by  rigidity  of  the  spine,  which  is 
shown  by  having  the  child  go  through  various  movements  in 
which  the  spine  is  necessarily  bent ;  by  pain  and  tenderness  in 
the  diseased  area ;  by  the  attitude  assumed,  which  is  often  char- 
acteristic ;  by  the  presence  of  the  typical  deformity  of  the 
spine  ;  by  paraplegia,  and  by  abscesses.  Rachitic  deformities 
are  more  gradual  in  their  curve,  and,  instead  of  mere  rigidity 
of  the  spine,  there  may  be  greater  mobility. 

Prognosis :  In  the  lumbar  and  cervical  regions  the  prog- 
nosis is  better  than  in  the  dorsal.  About  one -fourth  of  the 
cases  die  from  the  disease  sooner  or  later.  Death  occurs 
most  often  from  one  of  the  many  complications  that  are 
likely  to  arise  during  the  slow  course  of  the  disease.  In  the 
cases  which  recover  some  deformity  is  almost  certain  ;  but  its 


HIP  DISEASE.  327 

extent  depends  mainly   on   the  kind  of  treatment  and   the 
stage  at  which  it  was  begun. 

Pott's  disease— treatment :  The  general  treatment  ot  the 
patient  is  of  great  importance,  as  in  all  varieties  of  tubercu- 
losis. The  nutrition  should  be  carefully  attended  to,  fresh 
air  <rood  food,  cod-liver  oil,  and  iron  being  the  main  points 

of  value.  .  . 

Locally,  rest  to  the  diseased  parts,  with  proper  position,  is 
the  keynote  of  treatment,  This  may  be  gotten  by  long  con- 
finement to  bed,  or  by  the  use  of  proper  mechanical  supports 
which  allow  the  child  to  be  up  and  about,  For  details  ot 
mechanical  treatment  special  works  on  orthopaedics  are  to  be 
consulted. 

Kecently  these  cases  are  being  treated  by  forcible  reduction 
of  the  deformity,  and  then  the  application  of  a  proper  brace 
to  maintain  the  parts  in  position.  As  yet  the  value  of  this 
heroic  method  is  undecided. 

The  earlier  any  treatment  is  begun  the  better  the  results. 
Abscesses  and  sinuses  are  to  be  treated  on  general  surgical 
principles. 

HIP  DISEASE. 
Definition:  This  is  a  chronic  tubercular  inflammation  of 
the  structures  of  the  hip-joint,  and  is  very  common  in  child- 
hood. , 
Etiology :  Infection  bv  the  tubercle  bacillus  is  the  actual 
cause  of  this  disease.  A  slight  injury  to  the  joint  usually 
is  the  exciting  factor.  Delicate  children  and  those  with  a 
tubercular  family  history  are  most  often  the  victims.  Why 
the  hip  is  more  often  involved  in  children  than  other  joints 
is  unknown.  The  greatest  liability  to  the  disease  is  after  the 
third  year  of  life. 

Pathology:  The  disease  may  begin  m  the  head  ot  the 
femur,  in  the  acetabulum,  or  in  the  synovial  sac.  In  any 
case  it  rapidly  spreads  to  the  other  structures  of  the  joint. 
Then-  is  an  invasion  of  the  neighboring  parts  by  tubercular 
tissue,  which  destroys  the  bones  and  cartilages,  and  then  be- 

, ies  carious  and  breaks  down,  as  all  tubercular  tissue  does, 

with  the  formation  of  cold  abscesses. 


328  DISEASES  OF  THE  BONES. 

The  destruction  of  the  joint  in  the  old  cases  becomes  very- 
considerable,  the  head  of  the  femur  at  times  being  completely 
destroyed  and  the  acetabular  cavity  perforated. 

Hip  disease — symptoms :  For  descriptive  purposes  the 
symptoms  are  usually  divided  into  three  stages. 

In  the  first  stage  there  is  a  very  gradual  onset  of  the  symp- 
toms, and  ordinarily  a  slight  limp  is  the  first  thing  noticed. 
This  is  due  to  tenderness  in  the  joint  and  to  muscular  spasm. 
The  lameness  slowly  increases  in  severity  until  it  becomes 
very  evident  to  even  the  most  casual  observer.  Pain  also 
develops,  and  is  usually  referred  to  the  knee,  and  ordinarily 
is  worse  at  night.  On  careful  examination  during  this  stage 
there  will  be  found  limitation  of  motion,  due  to  muscular 
spasm,  in  almost  every  direction,  as  compared  with  the  oppo- 
site joint.  After  the  disease  has  lasted  a  short  time  there 
will  be  found  a  certain  amount  of  deformity,  the  muscles 
holding  the  joint  in  such  a  position  as  will  prevent  pressure 
on  the  inflamed  parts.  The  deformity  present  is  usually 
flexion,  abduction,  and  outward  rotation,  to  be  followed, 
later,  by  adduction  and  inward  rotation.  There  is  usually 
seen  quite  early  some  atrophy  of  the  muscles  on  the  affected 
side.     This  stage  may  last  two  or  three  years. 

In  the  second  stage  all  the  symptoms  of  the  first  stage  are 
aggravated.  The  deformity,  atrophy,  and  limitation  of  mo- 
tion, especially,  are  increased.  Pain  is  more  severe,  and 
sudden  crying  out  during  the  night  is  common.  During  this 
stage  breaking  down  of  tissue  and  formation  of  abscesses  occur, 
and  fever  makes  its  appearance.  The  abscesses  may  appear 
in  any  location  around  the  joint,  but  are  most  frequent  in 
front.  Some  rupture  into  the  pelvis.  After  rupture,  sinuses 
discharging  carious  tissue  and  pus  remain  indefinitely.  This 
stage  lasts  for  some  months  to  a  year. 

In  the  third  stage  the  deformity  is  very  marked.  In  addi- 
tion to  the  flexion  and  adduction  there  is  real  shortening 
from  destruction  of  the  head  of  the  femur.  The  atrophy 
becomes  more  marked,  the  suppuration  continues,  the  sinuses 
persist,  and  the  general  health  fails.  Tuberculosis  occurs 
elsewhere,  or  the  viscera  undergo  amyloid  degeneration. 
Even  after  this  stage  many  cases   recover  with  ankylosis  of 


KNEE-JOINT  DISEASE.  329 

the  joint,  but  most  of  them  die.  This  stage  may  be  pro- 
longed over  months  or  even  years. 

Diagnosis :  The  diagnosis  is  easy,  if,  with  lameness  and 
pain,  we  find  atrophy  and  limitation  of  motion.  Rheumatism 
is  the  disease  most  apt  to  be  confused. 

Prognosis :  While  the  tendency  in  this  disease  is  to  recov- 
ery, still  death  takes  place  in  a  considerable  proportion  of 
the  cases  from  exhaustion,  amyloid  disease,  or  general  tuber- 
culosis. If  recovery  occurs  in  the  first  stage,  there  is  scarcely 
any  deformity  left ;  but  in  the  second  or  third  stage  recovery 
is  accompanied  by  marked  deformity,  with  lameness  and 
atrophy  of  the  limb. 

Hip  disease — treatment :  Constitutional  treatment,  with 
highly  nutritious  foods,  cod-liver  oil,  iron,  and  fresh  air,  is 
very  important. 

Locally,  the  hip  is  to  be  put  at  rest  by  immobilization  of 
the  joint  by  extension  in  bed,  or  by  special  forms  of  ortho- 
paedic apparatus.  In  the  third  stage  the  question  of  surgical 
treatment  of  the  carious  joint  must  be  considered.  Abscesses 
and  sinuses  are  to  be  cared  for  on  general  surgical  principles. 

KNEE-JOINT  DISEASE. 

This  is  often  called  white  swelling,  and  is  a  tuberculosis  of 
the  knee-joint. 

Etiology :  It  is  due  to  infection  by  the  tubercle  bacillus, 
often  being  combined  with  slight  traumatism. 

Pathology:  It  begins  in  the  condyles  of  the  femur  or  the 
head  of  the  tibia,  or  the  synovial  membrane,  and  spreads  to 
the  joint-structures  proper,  the  normal  tissues  being  replaced 
by  new  tubercular  tissue.  This  undergoes  the  usual  necrotic 
process,  with  formation  of  abscesses. 

Knee-joint  disease — symptoms  :  Stiffness  of  the  joint,  pain 
and  tenderness,  and  a  limp  are  usually  first  noticed,  Later, 
swelling  of  the  ends  of  the  bone  and  atrophy  of  the  thigh-  and 
leg-muscles  follow.  There  is  limitation  of  motion,  with  de- 
formity, caused  by  muscular  contraction.  This  is  usually 
flexion,  with  later  a  partial  backward  dislocation  of  the  tibia. 
A-  the  case  advances,  motion  may  he  <n»tten  laterally, due  to 


330  DISEASES  OF  THE  BONES. 

destruction  of  the  lateral  ligaments ;  and  abscesses  form  and 
break  externally.  The  general  health  does  not  suffer  as  much 
as  in  hip  disease.     The  course  of  the  disease  is  very  chronic. 

Diagnosis  :  Rheumatism  is  most  apt  to  cause  confusion ;  but 
the  chronic  nature  of  the  disease,  and  the  bony  enlargement, 
and,  later,  the  spots  of  softening  and  formation  of  abscesses 
should  decide  the  diagnosis. 

Prognosis  :  It  is  a  less  fatal  disease  than  tuberculosis  of  the 
spine  or  hip ;  but  death  may  occur  from  tuberculosis  elsewhere, 
from  amyloid  degeneration,  or  from  exhaustion.  As  regards 
the  joint,  recovery  takes  place  usually  only  with  very  marked 
deformity,  unless  under  proper  treatment  begun  early. 

Knee-joint  disease — treatment :  The  same  constitutional 
treatment  is  necessary  as  in  hip  and  spine  disease.  Locally, 
the  joint  must  be  immobilized  in  good  position,  and  by  some 
apparatus  that  allows  the  child  to  be  up  and  about.  In  late 
cases  surgical  measures  may  be  required. 


TUBERCULAR  DACTYLITIS. 

Definition  :  This  is  a  chronic  tubercular  osteomyelitis  of  the 
phalanges  of  the  fingers.  It  is  seen  most  often  during  the 
second  and  third  years  of  life,  and  usually  in  children  with  a 
tubercular  heredity. 

Symptoms :  It  is  a  chronic  condition  seemingly  without 
much  pain  or  tenderness.  The  phalanx  swells  and  the  whole 
finger  gradually  enlarges  until  it  takes  on  a  fusiform  appear- 
ance. Later  the  soft  parts  are  involved,  including  the  skin, 
and  abscesses  form  and  burst,  discharging  Curdy  pus  and  bony 
detritus.  Inside  the  bone  shell  will  usually  be  found  a 
sequestrum.  The  disease  lasts  for  years  until  the  dead  bone 
is  all  discharged,  when  recovery  occurs  with  marked  deform- 
ity and  shortening,  and  a  useless  finger. 

Diagnosis  :  The  only  difficulty  comes  from  separating  this 
condition  from  syphilitic  dactylitis,  which  produces  almost 
the  same  lesions.  The  history,  other  signs  elsewhere,  and  the 
fact  that  syphilitic  disease  is  rare,  are  the  points  for  guidance. 

Prognosis  :  This  is  good  for  life,  unless  tuberculosis  should 


TUBERCULAR  DACTYLITIS.  331 

be  present  elsewhere,  but  a  badly  deformed  finger  is  usually 
left. 

Tubercular  dactylitis — treatment :  Constitutional  treatment 
to  build  up  the  general  health  is  of  most  importance.  Put 
the  finger  on  a  splint  which  will  keep  it  at  rest.  Open 
abscesses,  scrape  out  sinuses,  and  treat  the  part  on  general 
surgical  principles. 


CHAPTER    XVI. 
THE   INFECTIOUS   DISEASES. 

VACCINATION. 

Definition :  This  consists  in  inoculating  a  child  with  the 
dried  serum  from  a  vesicle  of  a  calf  which  has  vaccinia  or  cow- 
pox.  Vaccinia  in  a  calf  is  undoubtedly  variola  modified  by 
its  passage  through  a  number  of  generations  in  the  bovine 
species.  When  a  child  has  been  successfully  inoculated  with 
vaccine  it  is  protected  almost  absolutely  from  infection  by 
smallpox ;  but  in  the  few  cases  where  the  immunity  is  not 
perfect  the  child  undergoes  a  mild  attack  of  modified  small- 
pox, called  varioloid. 

Vaccination — time  for  performance  :  All  babies  had  best  be 
vaccinated  before  they  begin  cutting  teeth.  Re  vaccination 
should  be  performed  about  the  tenth  year,  and  again  at  about 
the  twentieth.  During  local  epidemics  of  smallpox  every 
one  who  has  not  been  vaccinated  successfully  within  five 
years  should  submit  to  the  operation. 

Vaccination — method  of  performance :  Fresh,  dried  virus 
from  the  calf  on  an  ivory  point  should  be  used.  The  left 
arm,  near  the  deltoid  insertion,  preferably ;  or,  in  girls,  the 
left  leg,  on  the  outer  side  of  the  calf,  should  be  washed  with  a 
little  alcohol.  The  operator's  hands  being  scrupulously  clean, 
with  a  new  fine  cambric  needle  a  small  square  should  be 
scratched  crosswise  until  the  blood  just  runs.  The  vaccine 
point  is  moistened  in  sterile  water,  and  the  lymph  then 
rubbed  thoroughly  into  the  wound.  The  blood  and  vaccine 
are  now  allowed  to  dry  completely  and  to  form  a  crust  over 
the  wound.  No  dressing  is  necessary  afterward,  but  the  part 
should  not  be  washed  nor  rubbed.  After  a  few  days,  if  there 
is  a  tendency  on  the  part  of  the  child  to  disturb  the  crust,  a 
light  sterile  dressing  may  be  bandaged  on  the  arm  for  pro- 

332 


VACCINATION  333 

tection.  On  no  account,  from  beginning  to  end,  must  the 
crust  be  removed,  as  it  forms  the  best  protection  to  the  wound. 
The  only  objection  to  using  the  leg  for  vaccination  is  the 
greater  difficulty  of  preventing  infection  of  the  wound. 

Vaccination — symptoms  :  Four  or  five  days  after  vaccination 
a  red  areola  is  seen  around  the  wound,  and  the  formation  of 
a  vesicle  around  the  circumference  begins.  From  the  seventh 
to  the  tenth  day  this  vesicle  becomes  fully  developed,  show- 
ing a  depressed  centre.  The  serum  in  the  vesicle  by  this 
time  begins  to  change  into  pus,  and  the  areola  around  the 
umbilicated  pustule  becomes  redder  and  more  marked.  The 
neighboring  lymphatic  glands  become  swollen  and  tender,  and 
for  a  time  the  region  around  the  vaccination  may  take  on  a 
very  angry  look.  The  pustule  very  gradually  dries  up  with 
the  formation  of  a  thick  crust,  the  inflammatory  action  de- 
creases, and  after  two  or  three  weeks  the  crust  drops  off, 
leaving  a  depressed,  pitted  scar,  which  remains  permanently. 

Constitutional  symptoms,  more  or  less  marked,  are  apt  to 
accompany  most  cases.  There  is  slight  or  rather  high  fever, 
with  its  accompanying  symptoms — headache,  anorexia,  and 
malaise.  These  begin  usually  with  the  formation  of  the  vesi- 
cle, and  last  for  a  few  days,  when  they  gradually  disappear. 

Vaccination — abnormalities :  Revaccinations  seldom  follow 
so  typical  a  course  as  the  first  vaccination. 

The  pustule  may  ulcerate  deeply  into  the  tissues  and  a 
large  slough  form,  leaving  a  deep  pit. 

Secondary  vesicles  may  form  around  the  original  one,  or 
even  inoculation  on  to  distant  parts  of  the  body,  through  the 
mucous  membranes  or  abrasions  of  the  skin,  may  take  place. 

Vaccination — complications:  Various  urticarial  and  erythem- 
atous eruptions  are  fairly  frequent  after  vaccination.  Ery- 
sipelas or  cellulitis  may  develop  from  the  wound,  either  from 
infection  at  the  time  of  vaccination  or  subsequently.  Boils 
and  small  abscesses  follow  in  some  cases. 

Inoculation  of  syphilis  or  tuberculosis  is  much  dreaded  and 
talked  about,  but  is  extremely  rare. 

Vaccination — treatment :  Prevent  the  wound  from  infection, 
subsequent  to  the  vaccination,  by  protecting  it  wirh  a  sterile 
dressing  after  the  formation  of  the  vesicle.     A  dry  powder, 


334  THE  INFECTIOUS  DISEASES. 

such  as  aristol,  may  be  dusted  on  if  the  suppuration  is  exces- 
sive. A  wet  dressing  of  lead  and  opium  is  useful  in  the 
later  stages  if  the  inflammation  is  severe. 

If  fever  needs  controlling,  small  doses  of  phenacetin  may 
be  used.     Complications  are  to  be  treated  as  usual. 

VARICELLA. 

Chickenpox  is  an  acute  contagious  disease,  consisting  of  a 
vesicular  eruption  with  very  few  constitutional  symptoms. 

Etiology :  It  is  very  much  commoner  in  children  than  in 
adults.  The  poison  is  given  off  from  the  surface  of  the  body, 
and  is  probably  contained  in  the  vesicles.  The  disease  is 
markedly  contagious.  No  specific  micro-organism  has  as  yet 
been  isolated.  One  attack  regularly  produces  a  permanent 
immunity. 

Incubation-period  :  This  is  regularly  from  thirteen  to  seven- 
teen days. 

Varicella — symptoms :  Ordinarily  the  eruption  is  the  first 
symptom,  although  there  may  be  some  fever  and  malaise 
during  the  preceding  day. 

The  eruption  comes  in  crops  beginning  as  papules,  which 
soon  turn  into  vesicles,  and  a  few  of  these  may  become 
pustules.  The  eruption  is  found  on  the  scalp  regularly  in 
the  beginning,  but  spreads  and  may  involve  any  part  of  the 
surface  of  the  body.  It  is  also  found  on  the  mucous  mem- 
brane of  the  mouth  and  pharynx.  The  eruption  runs  its 
course  in  about  five  days,  and  after  recovery  the  skin  is  left 
unchanged,  except  where  a  pustule  was  present,  when  a  pit 
will  be  left  behind. 

Varicella — complications  :  Infections  of  the  vesicles  are  the 
only  complications  to  be  dreaded.  Erysipelas,  sloughing  of 
the  skin,  and  acute  adenitis  may  be  present. 

Diagnosis  :  The  presence  of  vesicles  in  the  scalp  and  throat, 
and  the  absence,  of  any  marked  general  symptoms  are  the 
points  for  diagnosis. 

Prognosis  :  This  is  good,  as  only  complications  in  debilitated 
children  seem  dangerous. 

Varicella — treatment :  The    child   should   be   kept    in    the 


MEASLES.  335 


house,  and  away  from  school  and  other  children.  The  con- 
stitutional symptoms  are  usually  so  slight  as  to  need  no  treat- 
ment. If  the  fever  is  high  and  the  child  uncomfortable  from 
it,  a  little  phenacetin  may  be  given. 

Locally,  carbolized  vaseline  may  be  used  to  allay  the  itch- 
ing and  prevent  the  child  from  scratching. 


MEASLES. 

Measles  is  more  technically  called  rubeola,  and  also  morbilli. 
It  is  an  acute  contagious  disease,  characterized  by  fever,  catar- 
rhal inflammation  of  the  respiratory  tract,  and  a  diffuse  mac- 
culo-papular  eruption  on  the  skin  and  mucous  membranes. 

Etiology  :  The  disease  is  undoubtedly  due  to  some  micro- 
organism as  yet  unknown.  It  is,  next  to  smallpox,  the  most 
contagious  of  the  exanthemata,  and  very  few  of  the  human 
family  escape  it.  The  contagium  Is  given  off  from  the  mu- 
cous membranes  and  surface  of  the  body,  and  floats  in  the 
atmosphere.  One  attack  regularly  protects  from  subsequent 
ones. 

Incubation-period :  This  is  from  ten  to  fourteen  days. 

Measles— symptoms  :  The  invasion  is  marked  by  chilly  sen- 
sations, a  rather  rapid  rise  of  temperature,  headache,  vomit- 
ing, and  prostration.  General  convulsions  frequently  usher 
in  the  disease.  With  these  symptoms  catarrhal  inflamma- 
tions of  the  conjunctivae  are  regularly  seen.  There  may  be 
some  hoarseness  and  sore  throat  at  the  same  time.  The 
fever  remains  fairly  high,  and  with  it  are  headache,  backache, 
anorexia,  and  restlessness  or  drowsiness.  If  the  throat  is 
inspected  during  this  time,  isolated  red  spots  are  often  seen 
on  the  hard  palate,  and  pearl-colored  isolated  spots  on  the  in- 
side of  the  cheeks. 

After  three  to  four  days  this  period  of  invasion  is  suc- 
ceeded by  the  period  of  eruption.  The  typical  rash  of 
measles  consists  of  macules  and  papules,  which  appear  first 
around  the  scalp  and  on  the  face,  and  spread  downward  until 
they  usually  cover  the  entire  body.  By  the  time  the  lower 
extremities  are  involved  the  rash  has  about  faded  from  the 
head.     The  papules  are  isolated,  but  occur  in  patches,  which 


336  THE  INFECTIOUS  DISEASES. 

often  become  crescentic.  They  have  very  little  elevation 
above  the  surface  of  the  skin.  The  eruption  lasts  about  four 
days,  and  during  its  outbreak  all  the  constitutional  and  catar- 
rhal symptoms  are  exaggerated  ;  but  as  it  fades  these  also 
gradually  disappear.  The  throat  is  quite  painful,  and  swal- 
lowing is  difficult.  The  eyes  are  sensitive  to  light,  and  there 
is  regularly  a  laryngeal  or  bronchial  cough.  After  the  fading 
of  the  eruption  the  skin  begins  to  desquamate  in  fine  bran- 
like scales.     This  continues  for  a  week  or  ten  days. 

Measles — complications  :  Laryngitis,  bronchitis,  broncho- 
pneumonia, conjunctivitis,  adenitis,  otitis,  and  noma  are  the 
most  frequent  sequela?  of  measles. 

Abnormal  cases  :  Black,  or  malignant,  measles  is  a  form 
with  intense  infection,  a  hemorrhagic  eruption  in  the  skin, 
and  free  bleeding  from  the  mucous  membranes. 

Diagnosis  :  This  is  made  from  the  presence  of  coryza  and 
conjunctivitis,  combined  with  the  typical  eruption  on  the  skin 
and  hard  palate. 

Prognosis  :  Ordinarily,  in  healthy  children,  this  is  good. 
In  institutions,  and  among  people  where  the  disease  prevails 
for  the  first  time,  the  mortality  is  high.  Complicating  bron- 
cho-pneumonia is  the  usual  cause  of  death.  Most  of  the 
hemorrhagic  cases  die. 

Measles — treatment :  The  child  should  be  kept  in  bed  in  a 
room  with  a  steady  temperature  of  about  70°  F.,  and  which  is 
kept  darkened.  The  diet  should  be  almost  entirely  liquid, 
and  large  quantities  of  water  should  be  given.  The  bowels 
should  be  opened  by  fractional  doses  of  calomel,  and  this 
should  be  followed  by  some  mild  febrifuge,  such  as  a  small 
dose  of  phenacetin  every  four  hours,  or  of  tincture  of  acon- 
ite every  two  hours.  If  the  temperature  is  excessive,  cool 
sponging  is  to  be  used.  If  the  eruption  seems  delayed,  a  hot 
bath  may  be  given.  For  the  conjunctivitis  boric  acid  in  satu- 
rated solution  should  be  dropped  in  the  eyes,  and  the  edges 
of  the  lids  smeared  daily  with  vaseline.  During  desquama- 
tion frequent  warm  baths  and  the  application  of  very  small 
quantities  of  vaseline  to  the  skin  are  useful.  Some  cases 
with  intense  infection  will  require  alcoholic  stimulants. 

Complications  are  to  be  treated  as  usual,  and  special  pains 


ROTHELN— SCARLET  FEVER.  337 

are  to  be  taken  to  prevent  the  occurrence  of  bronchitis  or 
broncho-pneumonia. 

ROTHELN. 

This  is  also  called  rubella  or  German  measles.  It  is  a  con- 
tagious disease  of  mild  type,  characterized  by  a  rash  of  rather 
atypical  appearance,  and  by  slight  malaise. 

Etiology :  German  measles  is  probably  due  to  some  un- 
recognized germ  ;  is  contagious,  and  is  seen  in  epidemic  form. 
Adults  seem  equally  often  attacked  as  children.  One  attack 
confers  immunity,  but  never  against  measles  or  scarlet  fever. 

Incubation-period :  This  is  from  one  to  three  weeks.  It 
averages  two  weeks. 

Rotheln — symptoms :  There  may  be  a  very  slight  fever, 
100°  to  101°  F.,with  malaise,  a  little  headache,  and  sore  throat. 
The  rash  appears  very  early,  and  may  resemble,  although  it 
is  not  exactly  like,  that  of  measles  on  the  one  hand,  or  that 
of  scarlet  fever  on  the  other.  Most  cases  are  accompanied  by 
a  moderate  swelling  of  the  glands  along  the  posterior  border 
of  the  sterno-mastoid  muscles.  The  eruption  lasts  two  or 
three  days  only,  and  then  rapidly  disappears.  Some  slight 
desquamation  follows. 

Diagnosis  :  This  is  the  most  important  part  of  the  disease, 
and  except  in  epidemics  is  very  difficult  to  make  positively. 
The  points  of  value  are  the  almost  complete  absence  of  any 
constitutional  symptoms,  thus  differentiating  measles  and  scarlet 
fever  ;  the  enlarged  posterior  cervical  glands,  and  the  anoma- 
lous rash. 

Prognosis  seems  to  be  always  good. 

Treatment :  No  real  treatment  for  this  disease  is  necessary. 
Any  complications  may  be  cared  for  as  they  arise. 

SCARLET  FEVER. 

Definition:  This  disease,  also  called  scarlatina,  is  an  acute 
contagious  fever  characterized  by  sudden  onset,  the  early 
symptoms  being  fever,  sore  throat3  vomiting,  or  general  con- 
vulsions; and  Inter,  a  typical  eruption  on  the  skin  and  mucous 

membranes. 

22—D.  c 


338  THE  INFECTIOUS  DISEASES. 

Etiology :  It  is  undoubtedly  due  to  some  form  of  micro- 
organism, but  so  far  no  specific  germ  has  been  isolated.  The 
disease  is  distinctly  contagious  during  its  whole  course,  the 
poison  being  given  off  from  the  skin  and  by  the  breath,  and 
being  carried  by  clothing,  bedding,  and  other  articles  from 
one  place  to  another.  The  vitality  of  the  organism  is  very 
marked,  even  after  years  seeming  to  retain  its  contagiousness. 
Children  are  much  more  susceptible  to  scarlatina  than  are 
adults,  but  still  a  considerable  number  of  individuals  never 
take  the  disease.  Suckling  babies  seem  rather  immune  to 
scarlet  fever,  as  they  do  to  others  of  the  exanthemata.  One 
attack  regularly  protects  from  subsequent  attacks  of  this 
disease. 

Pathology :  The  characteristic  lesion  is  the  eruption  on  the 
skin  and  in  the  throat.  There  is  intense  hyperemia,  with 
dilatation  of  all  the  capillaries.  There  is  some  exudation  of 
inflammatory  products  into  the  tissue  of  the  true  skin,  with 
blocking  of  the  sweat-ducts.  In  reality  there  is  present  an 
acute  dermatitis. 

Complicating  lesions  are  often  found — inflammation  of  the 
Eustachian  tube,  suppurative  otitis,  cervical  adenitis,  and, 
most  important,  various  forms  of  nephritis,  either  acute  de- 
generation of  the  kidney,  or  acute  exudative  or  acute  diffuse 
nephritis. 

Incubation-period :  This  is  short,  being  from  two  to  seven 
days. 

Scarlet  fever — symptoms  :  The  period  of  invasion  begins 
acutely  with  rather  high  fever — 101°  to  104°  F. — sore  throat, 
often  vomiting,  and  frequently  general  convulsions.  The 
child  appears  decidedly  sick,  has  headache,  anorexia,  and 
often  diarrhoea,  and  complains  of  the  sore  throat;  all  these 
symptoms  being  somewhat  in  proportion  to  the  height  of  the 
fever. 

On  examining  the  throat  there  will  be  found  a  diffuse  bright 
redness  covering  the  tonsils,  pharynx,  and  hard  palate.  On 
looking  carefully  this  will  be  seen  to  be  made  up  of  fine  red 
points  massed  closely  together.  At  times  false  membranes 
may  be  seen  on  the  tonsils  even  this  early. 

After  one  to  three  days  the  period  of  eruption  succeeds 


SCARLET  FEVER.  339 

this  period  of  invasion.  The  characteristic  rash  consists  of 
minute  red  points  so  closely  packed  together  as  to  give  the 
appearance  of  a  diffuse  scarlet  color.  This  rash  may  be  con- 
tinuous or  appear  in  scattered  patches.  The  eruption  begins 
on  the  neck  and  upper  part  of  the  chest,  and  usually  spreads 
over  the  whole  body.  The  face  is  most  Jikely  to  escape.  The 
rash  from  beginning  to  end  lasts  from  three  to  ten  days.  In 
some  cases  the  rash  completely  disappears  in  a  few  hours. 

During  the  development  of  the  eruption  the  temperature 
rises  and  all  the  constitutional  symptoms  increase  in  severity  ; 
but  with  subsidence  of  the  rash  the  general  symptoms  and 
fever  gradually  disappear. 

After  the  rash  is  gone  a  general  desquamation  of  the  whole 
skin  begins,  and  continues  for  three  to  six  weeks.  This  des- 
quamation is  not  in  fine  scales,  as  after  measles,  but  in  large 
flakes,  and  in  some  places  long  strips  of  epidermis  peel  off. 
Where  the  skin  is  thick,  as  on  the  hands  and  feet,  the  flakes 
are  largest  and  the  process  lasts  the  longest. 

The  tongue  in  scarlet  fever  is  rather  characteristic.  During 
the  period  of  invasion  it  is  coated  white;  but  later,  during 
the  rash,  the  white  covering  disappears,  and  leaves  a  reddish 
surface,  with  raised  papilla?,  giving  the  so-called  "  strawberry- 
tongue  "  of  this  disease. 

Until  desquamation  is  complete  the  disease  is  not  over,  and 
danger  from  infection  is  present  even  if  the  child  seems  per- 
fectly well.  The  disease  in  different  cases  varies  in  severity 
from  very  mild  attacks,  through  the  typical  cases  as  above 
described,  to  the  very  malignant  ones  with  evidences  of  over- 
whelming infection,  as  marked  cerebral  symptoms,  and 
hemorrhages  into  the  skin  and  from  the  mucous  membranes. 

Scarlet  fever — complications :  The  complications  and  sequelae 
of  scarlet  fever  are  of  great  importance,  and  add  enormously 
to  its  seriousness. 

The  commonest  complication  is  a  catarrhal  inflammation  of 
the  pharynx  ami  tonsils.  This  does  not  add  much  to  the  dis- 
ease, but  paves  the  way  lor  another  and  much  more  serious 
condition — a  WOWpouS  inflammation  of  the  same  parts.  A 
false  membrane  is  formed  over  the  same  area,  and  may  spread 
to  the  naso-pharynx,  nose,  middle  ear,  or  larynx.     This  is  but 


340  THE  INFECTIOUS  DISEASES. 

very  rarely  due  to  the  Klebs-Loffler  bacillus,  ordinarily  only 
streptococci  being  present.  With  this  pseudo-membranous 
angina  there  are  great  swelling  of  the  lymphatic  glands  of 
the  neck,  general  symptoms  of  marked  sepsis,  and  often  com- 
plications in  the  ears,  lungs,  and  kidneys.  At  times  the  phar- 
yngitis may  be  so  severe  as  to  produce  gangrene,  with  slough- 
ing of  large  areas  in  the  throat. 

The  lymphatic  glands  of  the  neck  are  always  in  a  state  of 
more  or  less  inflammation,  it  often  being  severe  enough  to 
cause  suppuration  with  abscess-formation. 

The  middle  ears  are  very  frequently  inflamed  during  the 
course  of  scarlet  fever,  from  extension  of  the  inflammatory 
process  through  the  Eustachian  tubes  into  the  tympanum. 
Ordinarily  both  ears  are  involved,  and  the  inflammation  may 
be  catarrhal  or  suppurative.  With  otitis  there  are  some  rise 
of  temperature,  earache,  and,  usually,  later  a  discharge  from 
the  meatus,  with  more  or  less  deafness.  Many  cases  are  left 
permanently  deaf,  or  become  deaf-mutes  after  this  serious  com- 
plication. 

Meningitis,  pleurisy,  pericarditis,  endocarditis,  arthritis, 
and  broncho-pneumonia  are  infrequent  complications. 

The  most  important  complication  in  scarlatina  is  nephritis 
of  some  variety.  It  accompanies  almost  every  case  that  is  at 
all  severe,  the  poison  of  the  fever  being  evidently  very  irri- 
tating to  the  renal  epithelium.  It  may  take  the  form  of 
acute  degeneration  of  the  kidney  only  ;  or,  when  more  severe, 
may  be  acute  exudative  or  diffuse  nephritis.  The  two  former 
conditions  may  be  completely  recovered  from,  but  the  latter 
leaves  a  permanently  damaged  kidney  behind.  With  the  onset 
of  either  variety  the  urine  becomes  diminished  in  volume, 
and  subcutaneous  oedema  and  ursemic  symptoms  may  be 
present  in  some  of  the  severe  cases.  It  is  often  the  cause  of 
death. 

Diagnosis:  This  can  only  be  made  positively  after  the  de- 
velopment of  the  rash.  This,  combined  with  the  fairly  char- 
acteristic symptoms  of  invasion,  usually  marks  the  disease 
positively.  In  some  cases  with  very  slight  rash  the  diagnosis 
is  very  difficult.  The  occurrence  of  the  typical  desquamation 
afterward  is  always  of  assistance.     Urticaria,  erythema,  and 


SCARLET  FEVER.  341 

rbtheln  may  produce  similar  eruptions,  but  are  excluded  by 
the  absence  of'  signs  in  the  throat  and  the  general  symptoms. 

Prognosis  :  The  cases  vary  a  great  deal  in  severity  and  mor- 
tality in  different  epidemics.  The  younger  the  child,  as  a 
rule,  the  more  fatal  the  disease.  The  more  marked  the  symp- 
toms during  the  active  stage  of  the  attack  the  greater  is  the 
mortality-rate.  Complications  add  greatly  to  the  danger 
from  the  disease.  The  mortality-rate  in  a  large  series  of 
cases  averaged  from  12  to  15  per  cent.,  but  is  often  much 
lower  and  again  much  higher  than  this  in  local  epidemics. 

Scarlet  fever — treatment :  The  child  should  be  isolated  in 
one  room,  which  should  be  kept  well  ventilated  and  at  a  uni- 
form temperature  of  70°  F.  Unnecessary  furnishings  in  this 
room  should  be  removed,  and  the  nurse  and  others  who  of 
necessity  must  go  into  the  sick-room  should  frequently  use  a 
gargle  of  some  mild  antiseptic.  Those  going  into  and  out 
of  the  room  had  better  keep  hanging  at  the  door  a  long 
cotton  gown  to  wear  over  the  clothing  when  in  the  room. 

The  hands  should  be  carefully  washed  on  coming  out,  and 
a  short  exposure  to  fresh  air  is  advisable  before  coming  in 
contact  with  other  people.  The  patient  should  be  given 
every  day  a  complete  bath  of  warm  water  and  soap,  and  dur- 
ing the  period  of  desquamation  this  should  be  followed  by  a 
slight  greasing  of  the  whole  body  with  vaseline. 

For  the  care  of  the  disease  itself,  the  child  should  be  kept 
in  bed  during  the  whole  course  of  the  fever  and  constitutional 
symptoms.  The  diet  should  be  milk  only,  this  being  the  best 
preventive  of  a  complicating  nephritis.  If  the  child  cannot 
take  milk,  only  fluid  foods  of  other  kinds  should  be  allowed. 
Under  any  circumstances  an  abundance  of  water  should  be 
used.  This  diet  should  be  continued  for  some  little  time  after 
the  fever  has  subsided,  its  change  being  indicated  by  the 
results  of  careful   watching  of  the  condition  of  the  urine. 

Another  important  part  of  the  treatment  is  the  care  of  the 
mouth  and  tin-out,  to  prevent  complicating  adenitis  and  otitis. 

The  mouth  should  be  washed  frequently,  the  pharynx 
sprayed,  and  the  nose  douched  or  sprayed  with  some  mild 
antiseptic  like  Dobell's  solution. 

Otherwise  the  treatmenl    is   mainly  symptomatic.     If  the 


342  THE  INFECT TO  US  DISEASES. 

temperature  is  excessive,  it  may  be  controlled  by  cool  spong- 
ing or  small  doses  of  the  coal-tar  products.  The  cerebral 
symptoms  usually  accompany  the  high  temperature,  and  are 
best  treated  by  the  same  means ;  but  the  bromides  may  be 
given  in  addition,  if  they  become  too  excessive.  If  the  heart- 
action  becomes  feeble,  stimulants  are  to  be  used ;  the  best  of 
which  are  alcohol,  digitalis,  and  strychnine. 

Complications  are  to  be  treated  on  the  usual  plan — adenitis 
by  local  applications  of  ice,  and  incision  in  case  of  suppura- 
tion ;  otitis  by  heat  locally,  and  cleanliness  of  the  meatus ; 
and  nephritis  as  laid  down  in  the  description  of  this  disease. 

During  convalescence  care  with  the  diet  and  the  use  of 
iron  are  of  most  importance. 


ERYSIPELAS. 

Definition  :  This  is  an  acute  contagious  disease  characterized 
by  fever  and  its  accompanying  symptoms,  and  the  presence 
of  a  diffuse  red  rash  having  a  great  tendency  to  spread. 

Etiology  :  The  disease  is  due  to  infection  by  a  specific  micro- 
organism— the  streptococcus  of  Fehleisen.  It  is  communicated 
by  inoculation  through  an  abrasion  of  the  skin  or  mucous  mem- 
brane, but  the  point  of  inoculation  cannot  always  be  found. 
One  attack  does  not  confer  immunity  against  subsequent  in- 
fection. It  often  develops  in  wounds  received  accidentally, 
or  at  the  surgeon's  hands,  or  after  vaccination ;  but  many 
cases  of  the  so-called  idiopathic  form  develop  on  the  face  or 
elsewhere  from  a  wound  so  small  and  unimportant  as  to  be 
overlooked.  In  new-born  infants  it  often  develops  from  the 
navel  during  the  detachment  of  the  cord. 

Pathology :  There  is  a  marked  inflammation  of  the  true 
skin  and  of  the  subcutaneous  connective  tissue.  The  lym- 
phatics are  found  to  be  filled  with  streptococci.  The  skin 
becomes  congested,  swollen,  and  infiltrated  with  the  inflam- 
matory products,  with  at  times  an  excessive  emigration  of 
white  cells  and  the  formation  of  abscesses. 

Complicating  lesions  in  the  veins,  meninges,  pericardium, 
peritoneum,  kidneys,  and  lungs  are  often  found. 


ERYSIPELAS.  343 

Erysipelas — symptoms  :  After  an  incubation-period  of  from 
three  to  seven  days  the  child  is,  as  a  rule,  rather  suddenly 
attacked  with  a  chill  followed  by  fever,  prostration,  headache, 
and  loss  of  appetite.  Often  a  general  convulsion  marks  the 
onset  of  the  disease.  The  fever  remains  rather  uniform, 
averaging  100°  to  104°  F.,  and  all  the  constitutional  symp- 
toms continue.  The  characteristic  rash  appears  as  a  diffuse 
redness,  with  some  thickening  of  the  skin  and  consequently 
a  well-defined  raised  edge.  From  day  to  day  it  is  seen  to 
spread,  and  as  new  areas  are  involved  a  new  accession  of  fever 
and  often  a  slight  chill  appear.  The  eruption  ordinarily 
spreads  by  direct  continuity  of  tissue,  and  the  whole  body 
may  be  involved  ;  but  at  times  patches  are  seen  with  unin- 
flamed  skin  between.  Natural  lines  on  the  skin,  as  the  hair- 
line, bony  ridges,  or  creases,  often  seem  to  limit  the  spread 
of  the  rash. 

The  duration  of  the  disease  is  very  indefinite,  depending  on 
the  severity  of  the  infection,  the  limitation  of  the  spreading 
of  the  rash,  and  the  resistance  of  the  patient ;  but  the  fever 
and  constitutional  symptoms  continue  unabated  so  long  as  the 
disease  has  a  tendency  to  spread. 

Complications  :  Albuminuria,  pneumonia,  and  abscesses  are 
the  commonest  complications  of  the  disease. 

Diagnosis :  The  sharp  constitutional  symptoms,  combined 
with  the  typical  spreading  rash  with  its  raised  edge,  are  quite 
characteristic. 

Prognosis :  The  younger  the  child  the  more  fatal  the  dis- 
ease. In  the  new-born  death  is  to  be  expected.  In  children 
over  five  it  is  a  serious,  but  rarely  a  fatal  disease.  Complica- 
tions, naturally,  add  to  the  mortality-rate. 

Erysipelas — treatment:  The  child  is  to  be  kept  in  bed,  well 
nourished  according  to  its  age,  and  alcoholic  stimulants  used 
as  needed.  There  seems  t<»  be  -nine  value  in  the  use  inter- 
nally of  the  tincture  of  the  chloride  of  iron.  Special  symp- 
toms are  to  be  treated  as  they  aris< — excessive  lever  by  the 
external  use  of  cold  water  or  by  pheiiacetin  internally,  and 
great  restlessness  ;m<l  sleeplessness  by  the  use  of  bromides. 

Locally,  the  parts  should  be  kept  continuously  in  a  wet 
dressing  of  carbolic  acid,  1  percent.,  or  in  bichloride  of  mer- 


344  THE  INFECTIOUS  DISEASES. 

cury,   1  :  10,000.     These   may  be  alternated  with  a   10  per 
cent,   ichthyol  ointment,  or  other  similar  application. 

DIPHTHERIA. 

Definition  :  This  is  an  acute  contagious  disease  due  to  a  spe- 
cific bacillus,  and  characterized  by  the  growth  of  a  false  mem- 
brane on  some  one  of  the  mucous  membranes,  though  usually 
in  the  respiratory  tract.  It  may  or  may  not  be  accompanied 
by  constitutional  symptoms  of  varying  severity. 

Etiology :  Diphtheria  is  due  to  infection  by  the  Klebs- 
Loffler  bacillus.  It  exists  in  large  cities  as  an  endemic  dis- 
ease, and  epidemics  occur  from  time  to  time.  Children  are 
more  prone  to  the  disease  than  are  adults.  One  attack  does 
not  protect  from  future  attacks,  although  a  short-lived  im- 
munity is  produced.  The  bacilli  exist  in  the  pseudo-mem- 
brane, and  are  given  off  in  the  discharges  from  the  nose  and 
throat  of  the  patient.  They  may  live  on  clothing,  toys,  and 
in  the  fur  of  animals,  and  by  these  the  disease  may  be  spread 
to  other  children.  The  bacilli  frequently  remain  virulent  in 
the  throat  of  the  child  after  all  local  and  general  evidences 
of  the  disease  have  disappeared.  They  may  also  be  found 
in  the  throats  of  attendants  and  other  individuals  who  have 
no  clinical  signs  or  symptoms  of  the  disease. 

Children  who  have  any  abnormalities,  or  acute  or  chronic 
catarrhs  of  the  throat  or  naso-pharynx,  are  much  more  liable 
to  be  attacked  by  diphtheria  than  others. 

Pathology :  The  local  lesion  is  a  croupous  inflammation  of 
the  mucous  membrane  involved  in  the  diphtheritic  process. 
The  commonest  locations  are  the  tonsils,  pharynx,  nose, 
larynx,  trachea,  or  bronchi.  Other  mucous  membranes,  or 
even  the  skin  when  abraded,  may  be  involved.  The  mucous 
membrane  is  congested,  swollen,  and  infiltrated,  and  its  sur- 
face coated  with  a  false  membrane  composed  of  fibrin,  pus, 
and  necrotic  epithelium.  This  false  membrane  is  tightly  ad- 
herent to  the  mucous  membrane,  and  if  forcibly  removed  leaves 
a  raw,  bleeding  ulcer. 

Complicating  lesions,  due  to  the  presence  in  the  blood  of 
the  toxins  produced  by  the  diphtheria  bacilli,  are  seen  in  the 


^  'rl 


a.  Colonies  of  diphtheria  bacilli,  X  160. 


b.  Colonies  of  pseudo-diphtheria  bacilli,  X  160.      c.  Colonies  of  diphtheria  bacilli,  X  240. 


Mi     t  v 


d.  Diphtheria  bacilli,  X  1000 


For     o  ri  k.        v      .  r 


e.  Diphtheria  bacilli,  X  1000     /  Pseudo-diphtheria  bacilli,  X  1000.    g.  Stre] 


,T.        V"T 


/i    Streptococci,   ■    icwk>. 


/.  Strc]>tococci,  X  1000. 

Diphtheria  Bacilli  and  Streptococci. 


DIPHTHERIA.  345 

degeneration  of  the  essential  cells  of  various  organs  of  the 
body.  These  are  commonest  in  the  kidneys,  heart-muscles, 
peripheral  nerves,  liver,  and  spleen. 

Other  complications  are  due  to  coincident  infection  by 
various  streptococci,  among  which  are  adenitis  and  broncho- 
pneumonia. 

Incubation-period :  This  is  from  two  to  ten  days. 

Diphtheria — symptoms :  The  symptoms  are  local,  due  to  the 
inflammation  of  the  mucous  membrane  ;  and  general,  due  to 
absorption  of  the  toxins  of  the  Klebs-Loffler  bacilli  into  the 
system.  The  cases  vary  greatly  both  in  severity  of  the  con- 
stitutional symptoms  and  in  the  amount  and  location  of  false 
membrane  formed. 

The  local  symptoms  are  the  presence  on  ordinarily  some 
part  of  the  respiratory  mucous  membrane  of  the  characteristic 
whitish  patches  of  this  disease.  These  patches  may  be  seen 
on  the  tonsils  only,  or  on  other  parts  of  the  pharynx,  and 
may  be  continuous  or  with  intervals  between  them.  The 
pseudo-membrane  is  white,  or  gray,  or  black ;  it  cannot  be 
removed  without  leaving  a  raw,  bleeding  ulcer  behind,  and 
the  surrounding  mucous  membrane  is  swollen,  red,  and  in- 
flamed. The  parts  are  painful  and  tender  to  the  touch,  and 
dysphagia  is  present.  The  glands  under  the  jaw  are  coinci- 
dently  inflamed,  being  swollen  and  tender.  From  day  to  day 
the  pseudo-membrane  is  often  seen  to  spread  and  involve 
neighboring  parts. 

The  first  membrane  may  appear  in  the  nose,  or  naso- 
pharynx, or  larynx  and  out  of  sight.  In  the  two  former 
locations  its  presence  is  shown  by  a  severe  rhinitis,  with  irri- 
tating discharges  from  the  nose,  and  in  the  last  by  the  symp- 
toms of  croup.  These  false  membranes  may  be  thin  or  thick  ; 
and,  since  the  use;  of  bacteriological  diagnosis  in  this  disease, 
we  know  that  there  may  be  true  diphtheria,  as  shown  by  the 
presence  of  the  Klebs-Loffler  bacilli,  without  any  pseudo- 
membrane,  the  throat  being  simply  in  the  stale  of  catarrhal 
inflammation.  The  membrane  in  any  one  location  is  gradu- 
ally loosened  from  its  base,  and  is  discharged  on  an  average 
in  about  seven  days. 


346  THE  INFECTIOUS  DISEASES. 

The  constitutional  symptoms  in  some  cases  are  absolutely- 
absent,  or  so  slight  as  to  be  overlooked. 

The  disease,  however,  ordinarily  begins  with  a  chill  or  chilly 
sensations,  accompanied  by  a  rise  of  temperature.  The  fever 
continues  throughout  the  disease,  but  is  usually  of  only  mod- 
erate severity — 101°  to  102°  F.  Temperatures  over  104°  F. 
are  very  rare.  With  this  are  prostration,  headache,  vom- 
iting, and  diarrhoea.  The  heart's  action  is  ordinarily  rapid 
and  feeble,  and  diphtheria  is  pre-eminently  the  disease  in 
which  attacks  of  serious  heart-failure  are  to  be  dreaded. 
These  attacks  may  arise  suddenly  when  the  child  is  in  his 
ordinary  condition,  or  may  develop  more  slowly,  venous  con- 
gestion, dyspnoea,  and  rapid  feeble  pulse  being  the  signs  of 
the  failure.  Probably  in  most  cases  these  attacks  are  due  to 
degeneration  of  the  vagus  nerve  by  the  diphtheria  toxins. 

Diphtheria — abnormal  cases:  There  are  cases  without  very 
high  fever  and  with  no  large  quantity  of  membrane,  in  which 
the  child  seems  to  suifer,  and  usually  dies  from  an  intense 
septic  infection  or  toxaemia.  The  main  symptoms  here  are 
great  prostration  and  feeble  heart-action. 

There  are  others  where  the  only  symptoms  are  those  of  a 
laryngitis,  the  membrane  being  confined  to  the  larynx.  These 
are  described  under  Membranous  Laryngitis. 

Complicating  lesions  add  their  symptoms  to  those  of  the 
disease  proper,  as  obstructed  respiration  in  laryngeal  cases; 
rapid  breathing,  cough,  and  increased  prostration  in  broncho- 
pneumonia ;  diminished  urine  and  oedema  in  nephritis. 

Pseudo-diphtheria :  Since  the  introduction  of  the  systematic 
bacteriological  examination  of  cultures  from  most  cases  of 
diphtheria,  it  has  been  proved  that  there  is  such  a  thing  as 
clinical  diphtheria,  differing  scarcely  from  the  true  form,  ex- 
cept that  there  are  no  Klebs-Loffler  bacilli  in  the  pseudo- 
membrane,  but  instead  there  are  streptococci  only  as  its  cause. 
This  variety  has  been  called  pseudo-  or  streptococcus-diphthe- 
ria. Clinically  it  is  well  to  consider  the  two  forms  alike, 
although  the  Klebs-Loffler  diphtheria  is  the  more  serious  dis- 
ease of  the  two. 

Diphtheria — sequelae  :  There  occur  frequently  after  diph- 
theria paralyses  of  groups  of  muscles.     These  are  due  to  de- 


Diphtherial  infection  of  uvula  and  anterior  pillars  of  fauces,  show- 
ing the  disappearance  of  the  membrane  after  injection  of  antitoxic 
serum.  (a,  18  hours;  b,  24  hours,  and  c,  36  hours  after  injection.) 
(Williams.) 


DIPHTHERIA.  347 

generation  or  inflammation  of  the  peripheral  nerves,  due  to 
the  toxins  of  the  disease.  The  muscles  most  commonly  in- 
volved are  those  of  the  soft  palate,  of  the  pharynx,  of  the 
larynx,  of  the  eyes,  of  the  extremities,  and  of  respiration. 
Except  when  involving  the  last  set  of  muscles,  they  are  not 
dangerous  to  life.  After  considerable  time  the  power 
gradually  returns  to  the  paralyzed  muscles  as  the  nerves  are 
regenerated.  If  the  respiratory  muscles  are  affected,  death  is 
quite  likely  to  occur. 

Diagnosis:  Clinically,  the  presence  of  general  symptoms  of 
an  infectious  disease,  combined  with  the  characteristic  false 
membrane,  are  the  points  for  diagnosis.  This  membrane  is 
not  easily  wiped  away,  as  are  the  spots  in  follicular  tonsillitis. 
A  sanious  nasal  discharge  points  to  membrane  in  the  nose, 
and  laryngeal  symptoms  to  its  presence  in  the  larynx.  It  is 
practically  impossible  to  separate  the  cases  of  true  from  those 
of  false  diphtheria  positively  by  the  appearance  alone. 

Of  recent  years  our  diagnosis  is  made  more  certain  by  the 
aid  of  bacteriological  methods.  A  swab  culture  is  made  from 
the  throat,  and  this  allowed  to  incubate  for  twelve  to  eighteen 
hours.  At  the  end  of  this  time  the  little  colonies  are  stained 
and  examined  under  the  microscope,  and  the  presence  or 
absence  of  the  Klebs-Loffler  bacilli  proved.  This  is  of 
special  assistance  in  laryngeal  and  nasal  cases  where  no  mem- 
brane is  visible. 

Prognosis  :  This  is  very  uncertain,  as  the  age  of  the  patient, 
the  virulence  of  the  infection,  the  location  and  extent  of  the 
membrane,  and  the  presence  of  complications  all  enter  into 
the  prognosis.  The  younger  the  child  the  more  dangerous 
the  disease  When  the  membrane  remains  confined  to  the 
tonsil  only,  the  prognosis  is  quite  good.  Rapidly  spreading 
membrane  is  serious.  Laryngitis  and  broncho-pneumonia  are 
very  dangerous  complications.  The  cases  with  marked  evi- 
dences of  toxaemia  are  always  severe.  The  mortality  of 
pseudodiphtheria  is  far  less  than  that  of  the  real  form. 

Diphtheria — treatment:  The  same  preventive  measures 
should  be  taken  as  in  all  infectious  diseases.  The  patienl 
should  be  closely  isolated  ;  the  attendants  should  gargle  their 
throats    frequently;  the  outside  clothing   worn   in  the  room 


348  THE  INFECTIOUS  DISEASES. 

should  be  changed  before  going  elsewhere ;  discharges  from 
the  child's  mouth  and  nose  should  be  received  in  a  strong 
solution  of  mercuric  chloride ;  the  clothing  and  bedding  of 
the  patient  should  be  soaked  in  the  same  solution  or  burned  ; 
the  hangings  of  the  room  should  be  removed  before  putting 
the  child  in  it.  After  the  disease  is  over  the  walls  of  the 
room  should  be  washed  with  bichloride,  and  a  public 
funeral  should  not  be  allowed. 

Nowadays,  in  addition  to  the  old  practice  of  swabbing  out 
with  an  antiseptic  the  throats  of  children  who  have  been  exposed 
to  the  disease,  a  small  immunizing  dose  of  antitoxin  should 
be  given,  averaging  from  100  to  500  units,  according  to  the 
age  of  the  child.  For  this  purpose  there  seems  as  much  value 
in  administering  the  serum  by  mouth  as  subcutaneously. 

For  the  actual  care  of  the  disease,  the  child  should  be  kept 
absolutely  quiet  in  bed,  and  on  a  highly  nourishing  diet, 
mainly  of  milk,  and  other  easily  digested  soft  foods.  Gavage 
is  often  very  helpful  in  feeding  these  cases  when  they  will  not 
take  sufficient  nourishment.  The  room  should  be  well  venti- 
lated and  kept  at  an  equable  temperature.  Internally  there 
seems  some  value  in  giving  small  doses  of  bichloride  of 
mercury  every  four  hours.  As  stimulants,  whiskey  is  to  be 
given  in  rather  large  doses  frequently  repeated.  It  not  only 
stimulates  the  heart,  but  also  seems  to  neutralize  the  toxaemia. 
In  cases  of  failing  heart  strychnine  is  our  most  useful  remedy. 

Locally,  the  inflamed  parts  should  be  kept  clean.  If  the 
membrane  is  only  on  the  tonsils  and  pharynx,  frequent 
gentle  swabbing  with  weak  bichloride  solution  is  helpful.  If 
the  naso-pharynx  or  nose  is  involved,  the  nostrils  should  be 
washed  out  frequently  each  day  with  Seiler's  solution.  This 
is  best  done  by  a  simple  piston-  or  a  fountain-syringe.  The 
solution  should  go  in  one  nostril  and  out  the  other.  Laryn- 
gitis is  treated  locally  and  mechanically  as  described  under 
membranous  laryngitis. 

In  addition  to  these  measures,  all  cases  should  be  treated, 
as  soon  as  seen,  by  injecting  antitoxin.  The  initial  dose 
should  be  1000  to  3000  units,  or  even  more,  according  to  the 
age  of  the  child,  the  dose  being  repeated  in  about  eighteen 
hours  if  no  local  or  general  improvement  is  manifest.     It 


WHO  OPING-  CO  UGH  349 

may  be  given  a  third  or  a  fourth  time  at  the  same  interval  if 
needed.  Use  the  most  concentrated  serum,  as  the  size  of  the 
dose  is  smaller,  and  the  earlier  it  is  given  the  better  the 
result.  It  is  given  by  a  large-sized  hypodermic  syringe, 
under  aseptic  precautions,  and  may  be  inserted  under  the 
skin  of  the  back  or  the  side.  Signs  of  improvement  after 
antitoxin  are  seen  in  the  diminution  of  the  fever  and  con- 
stitutional symptoms,  and  in  the  stopping  of  the  spread  and 
the  loosening  of  the  membrane.  These  must  not  be  expected 
before  eighteen  hours.  Some  days  after  the  injection  in 
certain  cases  erythema,  urticaria,  and  joint-pains  are  noticed, 
but  they  usually  quickly  subside. 

The  results  of  the  use  of  antitoxin  have  been  most  grati- 
fying, particularly  in  the  laryngeal  cases,  intubation  and 
tracheotomy  being  less  often  required,  and  when  used,  saving 
more  lives. 

Complications  are  treated  as  always ;  post-diphtheritic  neu- 
ritis by  massage,  electricity,  and  strychnine.  Convalescence 
requires  the  use  of  iron,  combined  with  good  diet  and  plenty 
of  fresh  air. 

WHOOPING-COUGH. 

Definition :  This  disease,  also  called  pertussis,  is  an  infec- 
tious neurosis,  characterized  by  inflammation  of  the  respira- 
tory tract  and  a  peculiar  paroxysmal  cough. 

Etiology:  While  whooping-cough  is  probably  due  to  some 
germ,  as  yet  efforts  to  isolate  it  have  not  been  successful.  The 
poison  seems  to  be  given  off  in  the  breath,  to  float  in  the  air, 
and  to  be  inhaled.  Children  are  quite  susceptible  to  the  dis- 
ease, and  more  «o  than  are  adults.  One  attack  regularly  pro- 
duces immunity.  The  disease  exists  endemically  in  most 
cities,  but  epidemics  occur  from  time  to  time. 

Pathology:  Catarrhal  inflammations  of  the  larynx,  trachea, 
;ind  bronchi  are  regularly  found.  Broncho-pneumonia  exists 
as  a  frequent  complicating  lesion. 

Incubation-period:  This  is  probably  about  two  weeks,  but 
cannol  be  stated  positively. 

Whooping-cough — symptoms:  The  invasion  begins  with  a 
catarrh   of  the   larynx,  trachea,   or   bronchi.     This   lasts   for 


350  THE  INFECTIOUS  DISEASES. 

from  ten  days  to  two  weeks ;  but  instead  of  the  cough  im- 
proving, toward  the  end  of  this  period  it  grows  worse.  This 
catarrh  is  of  varying  degrees  of  severity,  but  regularly 
the  cough  seems  disproportionate  to  the  physical  signs  to 
be  found  in  the  chest.  There  is  scarcely  any  fever  or 
malaise. 

Toward  the  end  of  this  period  of  invasion  the  cough 
begins  to  assume  the  typical  character  which  has  given  its 
name  to  the  disease.  This  cough  comes  in  'paroxysms,  during 
which  the  child  coughs  continuously  for  some  seconds,  at  the 
same  time  holding  his  breath,  and  at  the  end  of  the  paroxysm 
taking  a  long  stridulous  inspiration,  which  produces  a  sound 
like  the  word  "  whoop."  Daring  this  attack  he  becomes 
blue  in  the  face,  the  eyeballs  become  prominent  and  suffused, 
the  veins  stand  out,  and  the  child  presents  the  appearance  of 
suffocation.  This  paroxysm  is  apt  to  be  repeated  two  or 
three  times,  the  inspiratory  whoop  being  given  at  the  end  of 
each,  until  some  tenacious  mucus  is  expelled  or  vomiting 
is  produced. 

It  may  be  some  hours  before  another  set  of  paroxysms 
begins.  The  child  grows  to  know  when  the  attacks  are 
coming,  and  will  stand  for  support  against  some  stationary 
object,  and  usually  with  his  hands  braced  on  his  knees. 
Epistaxis  is  often  an  accompaniment  of  a  severe  paroxysm, 
and  after  an  attack  the  child  is  very  exhausted  and  often  in 
a  profuse  perspiration.  These  paroxysms  are  usually  more 
frequent  by  night  than  by  day,  and  may  be  repeated  many 
times  in  the  twenty-four  hours.  They  vary  both  in  intensity 
and  frequency  very  much.  Exercise,  shouting,  crying, 
draughts,  eating,  drinking,  or  excitement  will  often  develop 
a  paroxysm. 

The  general  health  of  the  patient  suffers  mainly  from 
the  interference  with  sleep,  and  from  the  inability  to  retain 
sufficient  nourishment  on  the  irritable  stomach.  Owing  to 
this,  many  of  these  children  grow  very  emaciated. 

This  paroxysmal  stage  lasts  from  three  to  six  weeks,  but 
often  is  continued  over  a  much  longer  period.  In  some  cases 
a  whooping-habit  seems  to  be  developed,  which  lasts  many 
months.     This  disease  ordinarily  disappears  very  gradually, 


WHOOPING-COUGH.  351 

the  paroxysms  becoming  less  frequent  and  less  severe  until 
they  stop. 

Whooping-cough — physical  signs :  In  uncomplicated  cases 
auscultation  of  the  chest  gives  no  physical  signs.  If  bron- 
chitis is  present,  as  is  so  frequently  the  case,  the  coarse  rales 
and  sibilant  and  sonorous  breathing  of  this  disease  are 
found.  If  broncho-pneumonia  complicates  the  disease,  we 
find  the  characteristic  signs  of  this  lesion. 

Complications :  Bronchitis  and  broncho-pneumonia  are  the 
commonest  and  most  serious  complications  of  pertussis. 
Hemorrhages  from  the  nose  or  mouth,  into  the  conjunctiva, 
or  into  the  meninges,  are  seen  from  time  to  time.  The  frsenum 
of  the  tongue  is  apt  to  be  torn  by  the  persistent  coughing. 
The  vomiting  after  the  paroxysms  may  be  looked  on  as  a 
complication  when  it  is  so  severe  as  to  interfere  with  the 
child's  nutrition.  Convulsions  and  various  forms  of  cerebral 
paralyses  may  complicate  some  severe  cases  in  infancy. 
Hernia  and  prolapsus  ani  may  result.  A  latent  tuberculosis 
may  be  started  up  by  the  disease. 

Diagnosis :  The  typical  whoop  is  the  diagnostic  test  of  this 
disease ;  but  in  children  with  a  persistent  cough  without 
adequate  physical  signs  to  account  for  it,  and  especially 
if  it  appear  paroxysmal  and  accompanied  by  vomiting  and 
suffusion  of  the  eyes,  a  fairly  probable  diagnosis  may  be 
made.  The  presence  of  pertussis  in  the  neighborhood,  or 
a  history  of  exposure  to  the  disease,  aids  in  making  our 
diagnosis. 

Prognosis :  Whooping-cough  is  a  disease  frequently  occur- 
ring in  very  young  infants,  and  in  these  cases  it  is  an 
extremely  fatal  malady,  as  it  is  apt  to  be  complicated  by 
broncho-pneumonia,  which  in  itself  is  necessarily  fatal  during 
the  first  two  years  of  life.  In  older  children,  and  without 
complications,  it  is  not  much  to  be  dreaded.  Infancy  and 
complications  are  the  dangerous  sides  of  this  disease. 

Whooping-cough — treatment:  Children  with  pertussis  should 
not  be  allowed  to  attend  school  nor  to  mix  with  other  children. 
This  is  a  point  in  which  great  carelessness  exists  in  every 
community.  In  good  weather  the  sick  child  should  be  kept 
out  of  doors  a  great  deal,  if  lie   lias    no    pulmonary  coinplica- 


352  THE  INFECTIOUS  DISEASES. 

tions,  but  the  habit  of  taking  such  children  on  street-cars 
and  into  places  where  other  children  are  exposed,  is  to  be 
condemned.  If  the  weather  is  bad,  or  if  pulmonary  compli- 
cations prevent  the  child  being  out  of  doors,  care  should  be 
taken  to  keep  the  rooms  in  which  he  lives  well  ventilated  ; 
but  every  precaution  should  be  followed  to  prevent  his 
"  catching  cold."  The  child's  diet  should  be  carefully 
attended  to,  and  only  the  most  nourishing  and  easily  digesti- 
ble food  should  be  given.  If  vomiting  is  excessive  and  in- 
terferes with  the  child's  nutrition,  the  food  should  be  pre- 
digested.  Often  by  feeding  a  little  of  this  food  immediately 
after  a  paroxysm  accompanied  by  vomiting,  it  will  be  re- 
tained. In  some  cases  alcoholic  stimulants  will  be  useful.  If 
any  of  the  drugs  given  for  the  cough  seem  to  irritate  the 
stomach,  they  should  be  stopped. 

There  seems  some  value  in  the  child's  breathing  the  vapor 
from  creosote  or  carbolic  acid.  This  may  be  brought  about 
by  wearing  a  respirator  for  some  time  each  day,  on  which  a 
few  drops  of  the  medicament  are  placed,  or  by  having  the 
air  of  the  child's  room  contain  the  vapor  of  the  drug.  A 
so-called  vapo-cresoline  lamp  is  useful  for  this  purpose,  but 
either  drug  may  be  vaporized  in  an  ordinary  tea-kettle  quite 
as  well. 

Local  applications  made  directly  to  the  larynx  are  of  little 
value.  In  very  severe  paroxysms  with  threatening  convul- 
sions chloroform  may  be  used. 

Internally  almost  all  the  drugs  of  the  pharmacopoeia  have 
been  given.  Only  a  few  are  of  value,  and  in  some  cases 
even  these  fail.  Belladonna  in  increasing  doses  until  the 
early  poisonous  symptoms  of  the  drug  appear  is  often  very 
useful.  Antipyrin  seems  the  next  most  valuable  drug.  It 
often  controls  the  paroxysms  like  magic.  Bromoform  in  two- 
drop  doses  four  times  a  day  is  a  newer  remedy  of  some  value. 
In  some  cases  quinine  in  fairly  large  doses  helps.  It  is  often 
helpful  to  produce  good  sleep  by  the  use  of  a  hypnotic,  such 
as  bromide,  chloral,  trional,  or  sulfonal,  which  likewise  quiet 
the  reflex  excitability  of  the  child. 

Complications  in  the  lungs  should  be  treated  in  the  usual 
way. 


MUMPS.  353 


MUMPS. 


This  disease,  also  called  infectious  parotitis,  is  characterized 
by  constitutional  symptoms  and  inflammation  of  the  salivary 
glands. 

Etiology :  The  disease  is  contagious  from  person  to  person, 
but  does  not  seem  to  attack  infants  quite  as  readily  as  adoles- 
cents. No  specific  germ  has  as  yet  been  isolated.  One 
attack  protects  against  subsequent  ones. 

Pathology :  Only  one,  or  both,  parotids  are  involved.  The 
submaxillary  glands  mayor  may  not  be  coincidently  inflamed. 
The  inflammation  only  goes  to  the  point  of  congestion,  with 
swelling  and  obstruction  of  the  ducts.  Suppuration  is  very 
rare,  and  as  the  inflammation  subsides  the  gland  returns  to 
normal. 

Incubation-period :  This  varies  from  two  to  three  weeks. 

Mumps — symptoms:  The  constitutional  symptoms  begin 
early  and  last  three  to  five  days.  They  are  fever,  headache, 
irritability,  anorexia,  nausea,  and  prostration.  The  tem- 
perature is  from  100°  to  102°  F. ;  but  in  severe  cases  may 
reach  104°  F.  Coincidently  the  glands  become  painful, 
swollen,  and  tender,  and  the  mouth  dry.  Moving  the  jaw, 
as  in  talking  or  eating,  is  very  painful,  and  the  presence  of 
any  food  in  the  mouth  pungent  enough  to  excite  the  flow  of 
saliva  increases  the  pain.  This  is  the  reason  acids  were 
used  as  an  old  test  for  mumps.  One  gland  is  usually  inflamed 
a  day  or  two  before  the  other,  but  at  times  it  may  be  some  days 
before  the  second  gland  becomes  swollen.  The  submaxillary 
glands  may  be  inflamed  coincidently  or  later.  After  two  to 
three  days  the  swelling  of  the  glands  reaches  its  height,  and 
then  gradually  disappears.  The  disease  lasts  one  or  two 
weeks,  asthe  glands  become  inflamed  together,  or  subsequently. 

Complications:  In  infants  these  are  rare.  In  adolescents, 
inflammations  of  the  testicles,  breasts,  or  onirics  are  seen  in  a 
fail-  proportion  of  cases.  This  inflammation  usually  subsides 
without  injury  to  the  organ. 

Diagnosis:  An  idiopathic  inflammation  of  the  parotid  or 
submaxillary  gland-;  is  usually  mumps.  II  the  parotid  is 
swollen,  the  lobe  of  the  ear  stands  <>ui    from   the  head.     He 

23 — J>.  C. 


354  THE  INFECTIOUS  DISEASES. 

sure  the  swelling  is  not  due  to  some  of  the  cervical  lymph- 
glands. 

Prognosis:  This  is  almost  invariably  good,  as  recovery  is  to 
be  expected  in  a  few  clays  to  a  week. 

Mumps — treatment :  The  child  should  be  kept  in  the  house 
and  fairly  quiet.  The  diet  should  be  liquid  and  without 
much  flavor,  so  as  not  to  excite  the  salivary  glands  to  activity. 
If  fever  is  high,  a  little  phenacetin  should  be  given.  If  the 
glands  are  painful,  hot  applications  are  soothing.  Broken 
doses  of  calomel  are  well  given  at  the  beginning  of  the  attack. 

LA  GRIPPE. 

Definition :  This  disease,  also  called  epidemic  influenza,  and 
catarrhal  fever,  is  an  infectious  malady,  characterized  by 
fever,  pains,  prostration,  and  catarrhs  of  the  mucous  mem- 
branes. 

Etiology :  It  is  pretty  well  proven  now  that  grippe  is  due 
to  a  specific  germ,  the  bacillus  of  Pfeiffer.  The  disease  occurs 
epidemically  over  large  areas  of  territory,  and  also  endem- 
ically  after  the  epidemic  feature  has  passed.  The  germ 
seems  to  be  disseminated  in  the  atmosphere,  and  to  attack 
the  victims  mainly  in  the  winter  and  spring.  Infants  and 
children  seem  equally  prone  to  the  disease  with  adults.  One 
attack  does  not  confer  immunity  to  subsequent  ones. 

Pathology:  Catarrhal  inflammations  of  the  eyes,  nose, 
throat,  ears,  larynx,  bronchi,  or  intestines  are  found.  Com- 
plicating lobar  or  broncho-pneumonia  may  be  present. 

Incubation-period  :  This  is  probably  short,  from  a  few  hours 
to  a  few  days,  but  cannot  be  decided  positively. 

La  grippe — symptoms :  The  disease  usually  begins  rather 
suddenly  with  fever,  headache,  pains  in  the  back  and  limbs, 
and  marked  evidences  of  prostration.  The  fever  runs  from 
100°  to  104°  F.,  but  very  seldom  higher.  It  lasts  from 
two  days  to  a  week,  and  is  accompanied  by  anorexia,  nausea, 
vomiting,  and  often  diarrhoea.  In  infants  convulsions  may 
be  present,  and  restlessness,  insomnia,  and  irritability  are 
quite  common.  All  the  symptoms  gradually  disappear  in 
about  a  week  in  the  uncomplicated  cases. 


LA    GRIPPE.  355 

La  grippe — complications  :  Very  few  cases  run  their  course 
without  some  complication.  The  commonest  of  these  are  in 
the  respiratory  system.  Few  cases  occur  without  some  in- 
volvement of  the  nose  and  pharynx,  a  severe  rhino-pharyn- 
gitis being  almost  always  part  of  the  disease.  The  mucous 
membrane  of  the  frontal  sinuses  is  likewise  inflamed,  and 
thus  severe  frontal  headaches  are  produced. 

A  frequent  complication  is  involvement  of  the  middle  ear, 
and  an  acute  otitis  media,  with  its  symptoms  of  earache, 
deafness,  and  a  discharge,  follows. 

In  children  especially,  the  cervical  lymph-glands  are  very 
often  inflamed,  and  frequently  go  on  to  suppuration. 

The  larynx,  trachea,  and  larger  bronchi  are  likewise  usually 
involved  in  the  catarrhal  process,  producing  an  irritating, 
croupy  cough,  with  substernal  pain,  but  very  little  expectora- 
tion. 

All  the  above  inflammations  seem  to  be  almost  a  necessary 
part  of  the  attack  of  grippe,  and  very  few  cases  escape  with- 
out more  or  less  severe  evidences  of  these. 

More  unusual,  and  more  serious  complications  are  broncho- 
pneumonia and  lobai-  pneumonia.  One  or  the  other  variety 
of  inflammation  of  the  lung  is  seen  in  a  fair  proportion  of 
the  cases  of  influenza.  They  both  run  a  rather  irregular 
course,  the  toxic  symptoms  of  each  being  very  prominent,  the 
duration  prolonged,  and  the  mortality  high. 

In  some  children  the  gastro-enteric  system  seems  to  be  par- 
ticularly vulnerable  to  the  influenza  bacillus,  and  vomiting 
and  diarrhoea  are  the  prominent  symptoms  of  the  disease. 
This  complication,  however,  is  seldom  very  severe,  and 
recovery  is  the  rule. 

Diagnosis:  During  an  epidemic  the  diagnosis  is  rather  easy. 
Tn  sporadic  eases  the  diagnosis  is  best  made  by  excluding 
Other  conditions  by  the  absence  of  physical  signs.  Malaria 
is  differentiated  l>v  the  enlarged  spleen  and  plasrnodia;  pneu- 
monia, by  the  physical  signs  in  the  chesl  :  meningitis,  by  the 
retracted  head  and  ocular  palsies;  typhoid  fever,  l>\  the  tym- 
panites, rose  spots,  and  Widal  reaction. 

Prognosis:  When  uncomplicated  mo-t  all  of  die  children 
recover.      Pulmonary   complications  are  apt    in   be  serious, 


356  THE  INFECTIOUS  DISEASES. 

especially  broncho-pneumonia.      Latent  tuberculosis  is  often 
developed  by  an  attack  of  la  grippe. 

La  grippe — treatment :  The  child  should  be  put  to  bed  and 
kept  there  so  long  as  the  fever  continues.  The  diet  should  be 
nutritious  and  easily  digestible.  The  bowels  should  be  moved 
by  fractional  doses  of  calomel.  For  the  aching  and  fever, 
nothing  is  so  useful  as  phenacetin  and  salicylate  of  sodium, 
given  in  doses  suitable  to  the  child's  age.  Quinine  may  be 
added  in  some  cases  with  advantage.  Where  the  depression 
is  extreme,  alcoholic  stimulants  should  be  used  freely.  The 
respiratory  complications  are  best  treated  by  the  ammonium 
salts  combined  with  inhalations.  Convalescence  should  be 
carefully  watched,  and  general  tonic  treatment  followed  until 
full  strength  returns. 

TYPHOID  FEVER. 

Definition :  This  is  an  infectious  disease  due  to  a  specific 
germ,  and  characterized  by  a  rather  typical  course  of  fever 
with  its  attendant  symptoms,  and  lesions  in  the  lymphatic 
glands  of  the  intestines. 

Etiology  :  The  direct  cause  of  typhoid  is  infection  by  Eberth's 
typhoid  bacillus.  This  is  usually  taken  into  the  digestive 
tract  along  with  some  form  of  food  or  drink,  water  and  milk 
being  the  most  usual  carriers  of  the  germ.  It  exists  and 
multiplies  in  the  contents  of  the  intestines,  in  the  intestinal 
lesions,  the  lymphatic  glands,  the  spleen,  liver,  kidneys,  and 
the  blood.  They  are  discharged  from  the  body  with  the  faeces, 
and  can  live  outside  the  body  for  a  considerable  time. 

The  disease  is  very  rare  in  infants,  as  they  are  so  univers- 
ally fed  on  sterile  food.  In  children  it  occurs  more  com- 
monly, but  even  in  them  is  rarer  than  in  young  adults.  One 
attack  of  typhoid  regularly  produces  immunity  for  life. 

Pathology  :  There  is  swelling,  followed,  in  the  severer  cases, 
by  necrosis  and  ulceration  of  the  solitary  and  agminated 
glands  of  the  ileum  and  colon.  There  is  also  an  associated 
catarrhal  enteritis.  The  lymphatic  glands  of  the  mesentery 
are  swollen  and  inflamed,  but  rarely  go  to  suppuration.  The 
spleen  is  enlarged  considerably  and  soft.     There  is  a  degener- 


TYPHOID  FEVER.  357 

ation  01  the  essential  cells  of  the  liver  and  kidneys.  The 
heart-muscle  is  soft  and  flabby.  Complicating  inflammations 
may  be  found  in  the  lungs,  meninges,  peripheral  nerves,  and 
veins,  but  all  are  rather  rare  in  children. 

Incubation-period :  This  averages  from  one  to  two  weeks. 
The  first  symptoms  of  the  fever  are  so  indefinite  that  it  is 
hard  to  set  a  positive  period  of  incubation. 

Typhoid  fever — symptoms  :  The  course  and  natural  history 
of  the  disease  in  childhood  follow  fairly  well  the  type  as  seen 
in  the  adult,  except  that  all  the  symptoms  seem  less  severe. 

The  disease  begins  gradually  with  lassitude,  slight  head- 
ache, anorexia,  and  often  attacks  of  diarrhcea  ;  or  more  rarely 
rather  suddenly  with  a  quick  rise  of  temperature  and  pros- 
tration. The  fever  lasts  usually  three  weeks ;  during  the 
first  week,  each  day  showing  a  little  more  temperature  than 
the  preceding  day  ;  during  the  second  week  the  temperature 
remaining  fairly  uniform  ;  and  during  the  third  week,  declin- 
ing day  by  day  to  reach  normal  after  the  twenty-first  day. 

The  average  temperature  is  from  102°  to  104°  F.,  but  in 
more  marked  cases  it  reaches  105°  to  106°  F.  It  often  shows 
marked  variations  in  its  course,  complications  of  an  inflam- 
matory nature  tending  to  increase  it,  while  hemorrhages  and 
perforation  cause  it  to  fall.  It  may  be  prolonged  for  a  con- 
siderable time  beyond  the  three  weeks,  remaining  at  99^°  to 
101°  F.,  or  even  after  a  period  of  apyrexia  it  may  rise  again 
and  remain  up  without  a  distinct  relapse. 

The  heart's  action  grows  more  rapid  as  the  fever  progresses, 
but  in  this  disease  is  always  somewhat  slower  than  a  like 
amount  of  fever  from  another  cause  would  produce.  The 
pulse  retains  its  power,  but  is  apt  to  become  dicrotic  toward 
the  height  of  the  fever. 

The  tongue  is  coated  down  the  centre,  but  the  tip  and  edges 
remain  dean  and  the  tip  pointed.  The  mouth,  becomes  dry 
and  glazed,  and  sordes  develop  around  the  lips  and  teeth. 
Anorexia   is  a   regular  symptom. 

The  bowi  Is  are  more  often  constipated  than  loose,  but  when 
diarrhcea  exists  the  discharges  partake  of  the  "pea-soup" 
character  seen  in  adults.  The  abdomen  becomes  moderately 
distended  ami  tympanitic  .-it  some  time  during  the  course  of 


358  THE  INFECTIOUS  DISEASES. 

the  fever,  due  to  accumulation  of  gas  in  the  intestines. 
Tenderness  and  gurgling  in  the  right  iliac  region  are  unim- 
portant signs. 

The  spleen  is  regularly  enlarged,  so  as  to  be  felt  on  palpa- 
tion extending  some  inches  below  the  border  of  the  ribs. 
There  seems  some  connection  between  enlargement  of  this 
organ  and  absorption  from  the  intestinal  lesions. 

During  the  second  week  of  the  fever  the  characteristic  erup- 
tion of  the  disease  appears  in  the  shape  of  isolated,  rose- 
colored,  lenticular  spots,  slightly  elevated,  and  disappearing 
on  pressure.  They  are  usually  few  in  number,  appearing  on 
the  abdomen  and  chest,  and  coming  in  successive  crops  which 
last  about  three  days  each. 

The  nervous  symptoms  are  rather  marked  in  children  :  head- 
ache, restlessness,  irritability,  and  later  stupor  and  apathy. 
Picking  at  the  bed-clothes  and  subsultus  tendinum  are  not 
very  common.  In  some  cases  delirium,  hyperesthesia,  stiff- 
neck,  and  ocular  symptoms  may  be  severe  enough  to  suggest 
meningitis. 

The  children  usually  feel  quite  sick,  and  prostration  is 
enough  to  make  them  glad  to  stay  in  bed.  As  the  disease 
progresses,  emaciation  becomes  extreme,  and  bedsores  are  very 
liable  to  develop  over  bony  prominences. 

Intestincd  hemorrhages  are  not  very  common,  but  do  occur 
toward  the  end  of  the  second  or  the  beginning  of  the  third 
week.  They  may  be  single  or  repeated.  They  add  a  danger 
to  the  disease  in  showing  the  presence  of  rather  deep  ulcera- 
tions, but  in  themselves  are  rarely  fatal.  The  blood  is  usu- 
ally dark,  and  mixed  with  fsecal  matter. 

Intestinal  perforation  is  very  rare.  It  is  accompanied  by 
all  the  symptoms  of  intense  shock,  and  a  fatal  ending  is  soon 
to  be  expected.  Retention  of  urine  is  quite  a  common  symp- 
tom at  some  time  in  the  course  of  the  disease. 

Relapses  may  occur  at  any  time  for  two  weeks  after  the 
subsidence  of  the  fever.  They  are  always  shorter  in  duration 
and  milder  in  their  course  than  the  original  fever,  but  usually 
all  the  signs  and  symptoms  of  the  first  attack  are  reproduced. 

Typhoid  fever — complications  :  Slight  albuminuria  is  usually 
present  in  typhoid,  due  to  a  degeneration  of  the  kidney-cells. 


TYPHOID   FEVER.  359 

More  or  less  bronchitis  is  rather  common,  but  is  usually  con- 
fined to  the  larger  tubes.  Broncho-pneumonia  is  a  much 
rarer  as  well  as  more  serious  complication  of  typhoid.  Otitis 
media  is  fairly  common  if  attention  is  not  paid  to  cleanliness 
of  the  mouth  and  throat.  Phlebitis  and  venous  thrombosis 
develop  in  many  of  the  cases,  most  often  in  the  legs. 

Diagnosis  :  This  needs  for  its  confirmation  the  typical  fever, 
tympanites,  enlarged  spleen,  and  the  eruption. 

In  addition,  the  Widal  reaction  should  be  found  in  the 
blood  :  if  to  a  culture  of  typhoid  bacilli  a  drop  of  blood  from 
a  patient  suffering  from,  or  lately  recovered  from,  typhoid 
fever,  be  added,  the  bacilli  undergo  a  peculiar  agglutination, 
which  does  not  take  place  when  normal  blood,  or  blood  from 
other  diseases,  is  added.  This  test,  while  not  absolute,  if 
positive,  is  confirmatory. 

Malaria  is  differentiated  by  the  presence  of  plasmodia  in 
the  blood ;  tuberculosis  by  local  signs  of  that  disease ;  menin- 
gitis by  ocular  and  pupillary  signs  ;  and  the  various  forms  of 
enteritis  by  the  more  marked  intestinal  symptoms. 

Prognosis:  This  is  better  than  in  adults,  as  the  disease  is 
usually  milder  in  children. 

Typhoid  fever — treatment :  The  child  should  be  put  to  bed 
and  kept  there  at  least  two  weeks  after  the  fever  has  reached 
normal.  The  diet  should  be  milk,  or  milk  derivatives  only, 
if  possible;  but  if  an  idiosyncrasy  exists  against  this,  broths 
and  eggs  may  be  used.  If  constipation  is  present,  the  bowels 
should  be  moved  in  the  beginning  by  calomel,  and  afterward, 
at  least  every  other  day,  by  enema.  If  diarrhoea  is  not  ex- 
cessive, it  should  be  left  alone.  If  necessary,  it  may  be 
checked  by  bismuth  and  opium.  All  discharges  from  the 
bowels  should  be  received  into  vessels  containing  1  :  1000 
bichloride  of  mercury  solution,  and  allowed  to  remain  in  it 
at  least  an  hour  before  being  thrown  out.  All  bedding  and 
cloths  which  are  soiled  by  the  faecal  discharges  should  be 
soaked  in  the  same  solution,  or  boiled  thoroughly  by  them- 
selves. 

The  fever  had  besl  not  lie  treated  by  any  drugs  of  any 
nature  given  internally.  They  simply  control  the  symptoms 
without  doing  any  good.      If  the  temperature  is  102^-°  F.  or 


360  THE  INFECTIOUS  DISEASES. 

over,  cool  sponging,  or  cold  packs,  or  cold  bathing  should  be 
systematically  used  ;  being  guided  by  the  height  of  the  tem- 
perature and  the  reaction  of  the  child  as  to  the  choice  of 
methods.  As  temperature-reducers,  they  are  valuable  in- 
versely in  the  order  given.  The  temperature  of  the  water 
should  be  about  80°  to  85°  F.  in  either  form. 

The  mouth  and  tongue  should  be  carefully  cleaned  three  or 
four  times  a  day,  a  mixture  of  lemon-juice  and  glycerin  being 
very  useful  for  this  purpose. 

There  seems  some  value  in  giving  dilute  hydrochloric  acid 
in  five-to-ten  drop  doses  three  times  a  day,  throughout  the 
course  of  the  fever.  If  the  tympanites  is  severe,  use  turpen- 
tine stupes  to  the  abdomen  or  pass  a  rectal  tube.  If  the 
child  is  very  restless  and  sleepless,  or  delirious,  bromides  may 
be  used  as  needed.  Stimulants  in  the  shape  of  whiskey  or 
strong  wine,  are  usually  needed  in  the  last  week  of  the  fever. 
For  intestinal  hemorrhage  we  give  opium  and  apply  cold  to 
the  abdomen.  Intestinal  perforation  is  treated  by  morphine. 
Prevent  bedsores  in  the  usual  way,  and  be  on  the  watch  for 
retention  of  urine.  Care  must  be  taken  after  the  subsidence 
of  the  fever  in  returning  to  a  normal  diet,  and  this  should 
take  place  very  gradually.  Strychnine  and  iron  are  valuable 
during  the  convalescent  stage. 

MALARIA. 

Definition :  This  is  an  infectious  disease  due  to  the  presence 
in  the  blood  of  a  specific  organism  belonging  to  the  protozoa, 
and  characterized  by  fever,  enlarged  spleen,  and  cachexia. 

Etiology:  The  organism  causing  the  disease  was  first  de- 
scribed by  Laveran  in  1880,  and  named  the  plasmodium  ma- 
larias. It  exists  in  the  blood  and  destroys  the  red  blood-cells. 
We  do  not  know  in  all  cases  how  it  enters  the  blood ;  nor 
is  its  habitat  outside  the  human  species  exactly  located. 

There  seems,  however,  strong  proof  in  some  cases  that  cer- 
tain species  of  mosquito  contain  the  plasmodium  and  act  as 
the  infecting  agent. 

The  plasmodium  is  an  amoeboid  body  growing  in  the  red 
corpuscle,  absorbing  the  pigment  from  the  red  cell  into  itself, 


MALARIA.  361 

and,  as  a  paroxysm  approaches,  segmenting  into  a  number 
of  smaller  bodies,  each  of  which  probably  makes  its  way  into 
another  red  cell  to  go  through  a  similar  series  of  changes 
when  its  cycle  is  through. 

Different  varieties  of  malarial  poisoning  are  due  to  some- 
what different  species  of  plasmodia,  the  organism  of  inter- 
mittent fever  showing  some  morphological  differences  from 
that  of  remittent  or  sestivo-autumnal  fever. 

Malaria  attacks  persons  of  all  ages — children  as  well  as 
adults.  It  exists  endemically  in  certain  parts  of  the  country 
which  are  usually  low-lying  marshy  places,  and  is  especially 
prevalent  after  the  country  has  been  flooded  or  when  new 
ground  has  been  turned  up.  In  moist  Southern  climates  it  is 
especially  frequent.  It  occurs  most  commonly  in  the  spring 
and  fall,  being  rare  in  the  winter. 

Incubation-period :  The  poison  of  the  disease  may  produce 
symptoms  shortly  after  infection,  or  remain  latent  over  such 
considerable  periods  of  time  that  it  is  impossible  to  decide  on 
a  definite  time  of  incubation. 

Malaria — varieties :  There  are  two  fairly  distinct  types  of 
malarial  fever  seen — the  intermittent  and  the  remittent  or  ces- 
tivo-autumnal  form. 

Intermittent  fever  begins  suddenly  with  a  severe  chill,  fol- 
lowed by  a  rapid  rise  of  temperature  to  often  as  high  as  104° 
or  106°  F.,  and  after  a  few  hours  this  falls  equally  as  quickly 
to  normal  with  a  profuse  drenching  perspiration.  During  the 
fever  there  are  intense  headache,  backache,  prostration,  and 
often  nausea  and  vomiting.  In  infants  general  convulsions 
quite  commonly  occur  with  the  rise  of  temperature.  This 
paroxysm  is  repeated  daily  at  about  the  same  hour  in  the 
quotidian  form  or  on  alternate  days  in  the  tertian.  Between 
the  paroxysms  the  child  feels  perfectly  well  and  has  no  symp- 
toms. In  children  one  or  the  other  stage  of  the  paroxysm  is 
often  wanting,  the  attack  seldom  being  quite  as  typical  as  in 
the  adult. 

Remittent  fever :  In  this  form  the  disease  may  begin  sud- 
denly or  gradually,  or  may  follow  one  or  more  paroxysms  of 
the  intermittenl  type.  The  fever  ha- daily  remissions  in  its 
course,  but    naver    reaches    normal.     It    lasts   an    Indefinite 


362  THE  INFECTIOUS  DISEASES. 

length  of  time,  depending  on  treatment  and  on  the  patient's 
remaining  in  the  malarious  country. 

With  the  fever  the  child  suffers  from  headache,  backache, 
marked  prostration,  and  often  nausea  and  vomiting.  The 
tongue  is  coated  white,  the  pulse  is  rapid,  and  the  patient  fre- 
quently passes  into  the  so-called  "  typhoid  state."  In  chil- 
dren delirium,  restlessness,  sleeplessness,  and  often  convul- 
sions are  present.  These  cases  are  often  mild,  but  they 
frequently,  especially  in  the  South,  pass  into  the  pernicious 
form  of  fever,  with  an  accession  of  all  the  symptoms,  and 
often  with  a  fatal  ending. 

After  either  form  of  malarial  infection  has  lasted  for  a  suffi- 
cient length  of  time,  the  so-called  malarial  cachexia  develops. 
In  other  cases  it  is  seen  in  children  living  in  a  malarious 
country,  even  with  no  signs  of  preceding  fever. 

This  cachexia  is  due  to  the  rapid  destruction  of  the  red 
blood-corpuscles  by  the  plasmodia.  The  children  are  pale, 
feeble,  languid,  and  emaciated.,  They  have  headaches  and 
digestive  disturbances.  An  examination  of  the  blood  will 
show  the  presence  of  a  high  degree  of  secondary  ansemia,  and 
of  plasmodia  in  the  red  cells. 

Malaria — diagnosis :  In  intermittent  fever  the  paroxysm  is 
so  characteristic  as  to  settle  the  diagnosis  easily.  In  the  re- 
mittent form  the  diagnosis  from  typhoid  is  very  difficult.  In 
all  varieties  we  expect  to  find  the  spleen  enlarged  enough  to 
be  easily  palpated,  and  in  addition  a  careful  searching  of  the 
blood  for  plasmodia  will  usually  find  them,  and  thus  settle 
the  diagnosis  positively.  The  therapeutic  test  with  quinine  is 
always  helpful.  Be  careful  not  to  overlook  other  conditions 
by  carelessly  calling  them  malaria. 

Prognosis :  This  is  good  if  the  disease  is  recognized  early 
and  properly  treated.  Removal  from  a  malarious  district 
adds  much  to  a  good  prognosis. 

Malaria — treatment :  During  a  chill  hot  applications  should 
be  made  externally  and  a  good  dose  of  hot  whiskey  be  given. 

After  the  chill  is  over  the  bowels  should  be  opened  by  a 
dose  of  calomel,  and  then  quinine  be  given  in  properly  sized 
doses  for  the  severity  of  the  infection  and  the  age  of  the  child. 


SYPHILIS.  363 

Children  bear  quinine  well,  and  should  be  given  relatively 
large  doses.  If  the  malaria  is  in  the  form  of  well-marked 
intermittent  fever,  a  couple  of  large  doses  at  an  hour's  inter- 
val, and  the  last  one  about  five  hours  before  the  expected 
paroxysm,  is  the  best  way  of  giving  it. 

In  the  irregular  attacks  and  in  the  remittent  forms  it  should 
be  given  regularly  in  good-sized  dose  three  times  a  day.  It 
should  be  continued  in  gradually  decreasing  doses  for  several 
days  after  all  evidences  of  the  infection  are  gone,  and  the  en- 
largement of  the  spleen  has  disappeared. 

For  children  who  can  swallow  capsules,  this  is  the  best 
method  of  giving  quinine.  If  it  must  be  given  in  solution, 
it  is  best  disguised  by  the  syrup  of  yerba  santa.  When  small 
doses  only  are  required,  the  chocolate  quinine  tablets  may  be 
used,  each  tablet  containing  one  grain  of  the  tannate.  If  it 
cannot  be  given  by  mouth,  it  may  be  given  by  rectum,  either 
in  enema  or  by  suppository,  a  double  dose  of  the  bisulphate 
being  used. 

In  malarial  cachexia  arsenic  should  be  given  with  the  qui- 
nine. 

SYPHILIS. 

Definition :  This  is  a  chronic  infectious  disease,  probably 
due  to  some  specific  germ  ;  but  as  yet  none  has  been  isolated 
and  proven  to  be  the  real  cause. 

Forms:  In  infancy  and  childhood  the  disease  maybe  ac- 
guired  in  many  ways  just  as  in  adult  life,  but  is  more  often 
inherited,  and  is  then  called  hereditary  or  congenital  syphilis. 

Acquired  syphilis  differs  in  no  respect  from  the  disease  as 
seen  in  adults,  and  so  will  receive  no  separate  description. 

In  inherited  syphilis  the  symptoms  seem  somewhat  modi- 
fied from  the  regular  course  and  require  special  consideration, 
and  iu  this  article,  when  using  the  term  syphilis,  the  congen- 
ital variety  will  l»e  understood. 

Etiology:  The  disease  may  originate  in  the  foetus  from  the 
father,  the  mother,  or  from  both  parents.  Parents  in  the 
secondary  stage  of  the  disease  are  almosi  certain  to  transmit 
the  taint.  If  in  the  tertiary  stage,  ox  after  prolonged  and 
proper  treatment,  the  danger  is  rather  slight.     There  seems 


364  THE  INFECTIOUS  DISEASES. 

less  danger  of  transmission  from  a  syphilitic  mother  than 
from  a  syphilitic  father.  If  the  mother  is  infected  late  in 
her  pregnancy,  the  child  will  often  escape. 

Pathology :  The  lesions  in  babies  dying  of  syphilis  are  not 
by  any  means  always  characteristic.  There  are  usually  found 
in  the  viscera  certain  changes  of  the  nature  of  a  new  growth 
of  connective  tissue,  which  replaces  the  proper  structure  of 
the  organ  involved.  For  instance,  there  may  be  fibroid 
changes  found  in  the  spleen,  liver,  lung,  or  kidneys,  giving 
these  organs  the  characteristic  whitish  color  and  tough  con- 
sistency which  are  always  found  in  interstitial  hyperplasia. 
The  capsules  of  these  organs  are  thickened  and  adherent,  and 
the  whole  organ  is  usually  enlarged. 

In  the  bones  the  lesions  are  quite  characteristic  and  more 
regularly  found.  There  is  usually  an  inflammatory  process 
present  at  the  junction  of  the  shaft  of  the  long  bones  with 
the  epiphysis.  This  consists  of  congestion  and  greatly  in- 
creased proliferation  of  cartilage-cells.  This  may  be  found 
in  only  one  or  in  many  of  the  bones,  and  may  lead  to  separa- 
tion of  the  epiphysis  and  diaphysis.  These  changes  are  often 
found  in  the  metatarsal  and  metacarpal  bones  and  in  the 
phalanges,  producing  syphilitic  dactylitis. 

In  the  late  cases  there  are  found  osteophytic  growths  on  the 
shafts  of  the  long  bones,  due  to  a  chronic  periostitis,  with  the 
formation  of  new  bone-tissue  under  the  periosteum.  This 
produces  great  enlargement  and  thickening  of  the  aiFected 
bone.     These  thickenings  may  be  uniform  or  in  nodes. 

Syphilis — symptoms :  According  to  the  virulence  of  the  in- 
fection and  the  period  of  incubation  in  the  individual  foetus, 
depends  the  condition  of  the  child  at  birth.  We  must  bear 
in  mind  that  what  corresponds  in  the  acquired  disease  to  the 
first  period  of  incubation,  (until  the  appearance  of  the  initial 
lesion  ;)  and  to  the  second  period  of  incubation,  (until  the  ap- 
pearance of  the  secondary  symptoms),  takes  place  during  intra- 
uterine life  in  the  inherited  form.  In  other  words,  the  infant 
is  ordinarily  born  during  the  second  period  of  incubation  ; 
and,  more  rarely,  after  the  secondary  symptoms  have  begun 
to  appear.  Accordingly,  abortion  may  take  place,  and  fre- 
quently does  ;  or  a  dead,  premature,  or  full-term  child  may  be 


SYPHILIS.  365 

born  ;  or  a  living  child  with  skin  lesions  and  other  evident 
signs  of  the  disease  may  come  into  the  world  ;  but  most  com- 
monly a  living  child  is  born  with  no  external  evidences  of 
disease. 

In  infants  born  with  evident  syphilis  present  the  symptoms 
are  a  marked  degree  of  malnutrition,  with  wasted  body, 
wrinkled  skin,  and  senile  appearance.  In  addition,  the  baby 
regularly  has  various  kinds  of  skin  eruption  present.  The 
eruption  may  be  papular  or  pustular,  but  the  characteristic 
form  is  that  of  pemphigus,  and  this  is  usually  found  on  the 
palms  and  soles.  Many  of  the  bullae  dry  and  form  yellow 
crusts  on  different  parts  of  the  body.  These  infants  usually 
live  but  a  short  time. 

In  the  ordinary  case  the  infant  appears  healthy  at  birth. 
During  the  first  month  these  children  show  some  aneemia  and 
other  evidences  of  malnutrition.  By  the  second  month,  usu- 
ally the  first  signs  of  the  disease  develop.  These  are  a  per- 
sistent coryza,  called  "  snuffles,"  and  the  eruption.  As  in  all 
syphilitic  eruptions  this  is  multiform,  and  may  be  a  simple 
erythema  or  roseola,  or  may  consist  of  macules,  papules,  ves- 
icles, or  pustules.  It  may  develop  anywhere  on  the  body, 
but  is  most  apt  to  appear  in  regions  where  irritation  is  great- 
est, as  around  the  buttocks.  Associated  with  these  skin  erup- 
tions are  the  frequent  occurrence  at  the  muco-cutaneous  junc- 
tions of  ulcers,  fissures,  mucous  patches,  and  condylomata. 
These  form  the  rhagades  about  the  lips  and  nostrils,  and  the 
ulcers  and  warts  around  the  anus.  During  this  time  more  or 
less  inflammation  about  the  nails  is  also  common. 

The  epiphysitis  occurring  at  this  time  produces  [tain,  tender- 
ness, and  often  swelling  about  the  joints.  From  this  comes 
a  voluntary  immobility  of  the  joint — a  pseudo-paralysis. 
Anaemia  and  marasmus  go  on  increasing  during  the  course  of 
the  disease,  and  from  time  to  time  fever  may  be  present.  The 
spleen  and  liver  are  regularly  enlarged,  but  not  the  lymphatic 
glands,  as  in  the  acquired  form. 

The  child  frequently  dies  of  marasmus  or  of  some  intercur- 
renl  trouble  during  the  course  of  the  disease  ;  but  if  the  in- 
fection is  mild  or  if  treatment  i-  given,  tie-  evidences  of  active 
disease,  the  secondaries  as  they  really  are,  gradually  disappear. 


366  THE  INFECTIOUS  DISEASES. 

Later,  often  about  the  tenth  year,  signs  of  late  syphilis  or 
what  might  be  called  the  tertiary  stage  of  the  disease,  de- 
velop in  many  of  these  surviving  children.  These  signs  are 
seen  most  frequently  in  the  teeth,  eyes,  ears,  and  bones. 

The  teeth  belonging  to  the  permanent  set  take  on  the  char- 
acteristics known  as  Hutchinson's  teeth.  In  this  condition  the 
upper  central  incisors  are  deeply  notched  by  a  crescentic  de- 
pression in  their  cutting-edge,  and  the  teeth  themselves  are 
shaped  like  a  peg  or  the  end  of  a  screw-driver. 

In  the  eye  the  cornea  undergoes  an  interstitial  inflammation 
with  the  production  of  opacities. 

In  the  ear  there  is  a  gradual  loss  of  hearing  without  signs 
of  inflammatory  action. 

In  the  bones,  the  changes  due  to  chronic  periostitis  are  seen, 
with  the  production  of  enlargements  and  thickenings  of  the 
long  bones,  as  the  tibia?,  and  the  growth  of  nodes  on  the  flat 
bones — those  of  the  cranium. 

Gummata  may  form  anywhere  in  the  skin  or  mucous  mem- 
branes. If  untreated,  they  break  down  and  form  ulcers  when 
in  the  skin  ;  but  when  in  the  mucous  membranes  of  the  nose 
and  hard  palate,  as  they  break  down  they  produce  destruction 
of  the  nasal  and  palate  bones,  with  perforations  and  deformi- 
ties of  these  parts.  Gummata  may  likewise  form  in  the  vis- 
cera, but  are  usually  not  diagnosed  in  these  situations. 

Syphilis — diagnosis  :  In  well-marked  cases  this  is  not  diffi- 
cult. If  an  eruption  only  is  present,  it  is  more  difficult ; 
and  the  mother's  history  must  be  taken  into  consideration  as 
to  previous  abortions,  birth  of  dead  children  or  of  children 
with  eruptions.  The  coryza,  fissures  about  the  lips,  condy- 
lomata about  the  anus,  signs  of  epiphysitis,  eruption,  and 
malnutrition  are  the  points  to  be  looked  for. 

In  the  tertiary  stage,  Hutchinson's  teeth,  interstitial  kera- 
titis, deafness,  deformities  of  the  nose  and  palate,  and  enlarge- 
ments of  the  tibiae  are  typical  signs. 

Prognosis  :  This  is  a  more  dangerous  disease  in  infants  than 
in  adults,  as  the  malnutrition  so  interferes  with  their  growth. 
The  earlier  after  birth  the  symptoms  develop  the  worse  the 
prognosis.  Much  depends  on  the  way  treatment  is  carried 
out  in  estimating  the  prognosis. 


SYPHILIS.  367 

Syphilis — treatment:  All  the  ordinary  means  for  the  pre- 
vention of  syphilis  should  be  carried  out.  If  a  mother  be- 
comes pregnant  with  what  may  be  a  syphilitic  child,  she 
should  be  vigorously  treated  throughout  her  pregnancy. 

Just  as  soon  as  a  diagnosis  is  made  the  child  should  be 
put  under  mercurial  treatment.  It  is  best  given  by  inunction, 
using  about  one  scruple  of  blue  ointment  daily.  The  place 
of  rubbing  should  be  changed  from  day  to  day  to  avoid  irri- 
tating the  skin.  Internally,  gray  powder  in  grain  doses  three 
times  a  day,  or  bichloride  of  mercury,  gr.  -£$,  three  times  a 
day,  may  be  given.  Salivation  is  rare  in  children,  but  diar- 
rhoea may  be  started. 

Locally,  calomel  powder  or  a  calomel  ointment  is  the  best 
application  for  fissures,  ulcers,  and  condylomata. 

In  the  tertiary  stage  large  doses  of  iodide  of  potassium  are 
to  be  given. 

Through  all  treatment  special  care  should  be  given  to 
hygiene  and  food,,  and  the  use  of  iron  from  time  to  time  is  to 
be  recommended. 


INDEX. 


A. 

Abdomen  at  birth,  19 
Abscess,  alveolar,  80 
ischio-rectal,  138 
peritonsillar,  85 
retro-oesophageal,  89 
retropharyngeal,  81 
Addison's  disease,  204 

diagnosis  of,  205 

etiology  of,  204 

pathology  of,  205 

prognosis  of,  205 

symptoms  of,  205 

treatment  of,  205 
Adenitis,  acute,  306 

diagnosis  of,  307 

etiology  of,  306 

pathology  of,  306 

prognosis  of,  307 

symptoms  of,  306 

treatment  of,  307 
chronic.  307 

diagnosis  of,  308 

etiology  of,  308 

pathology  of,  308 

prognosis  of,  308 

symptoms  of,  308 

treatment  of,  308 
tubercular,  308 

diagnosis  of,  310 

etiology  of,  308 

pathology  of,  309 

prognosis  of,  310 

symptoms  of,  309 

t  real  menl  of,  310 
Adenoids  of  naso-pharynx,  83 
Adhsesia  linguse,  7:» 

treatmenl  of,  79 
Amyloid  liver,  1  16 

pathology  of,  1 16 

symptoms  of,  1  16 

treatment  of.   1  Hi 
Anemia,  pernicious,  199 

diagnosis  of,  200    $ 

21-D.  C, 


Anaemia,  pernicious,  etiology  of,  199 

pathology  of,  199 

prognosis  of,  200 

symptoms  of,  200 

treatment  of,  200 
secondary,  198 

diagnosis  of,  199 

etiology  of,  198 

pathology  of,  198 

prognosis  of,  199 

symptoms  of,  198 

treatment  of,  199 
simple,  197 

diagnosis  of,  198 

etiology  of,  197 

pathology  of,  197 

physical  signs  of,  197 

prognosis  of,  198 

symptoms  of,  197 

treatment  of,  198 
Anus,  diseases  of,  135 

acute  proctitis,  139 

fissura  ani,  137 

fistula  in  ano,  138 

hemorrhoids,  137 

ischio-rectal  abscess,  138 

prolapsus  ani,  136 

pruritus  ani,  135 
Appendicitis,  119 
causes  of,  119 
diagnosis  of,  121 
etiology  of,  119 
pathology  of,  119 
prognosis  of,  122 
symptoms  of,  120 
treatment  of,  122 
Arteries  and  veins,  diseases  of,  193 
acute  phlebitis,  L94 
Chronic  endarteritis,  193 
Arthrii  is,  acute,  324 

diagnosis  of,  32 1 

etiology  of,  324 

pathology  of,  324 

prognosis  of,  325 

symptoms  of,  324 

369 


370 


INDEX. 


Arthritis,  acute,  treatment  of,  325 
Asphyxia  in  the  new-born,  31 

treatment  of,  31 
Asthma,  243 

diagnosis  of,  244 

etiology  of,  244 

physical  signs  of,  244 

prognosis  of,  244 

symptoms  of,  244 

treatment,  of,  244 
Autumnal  catarrh,  219 

B. 

Balanitis,  270 
etiology  of,  270 
symptoms  of,  270 
treatment  of,  270 
Bladder,  extrophy  of,  in  the  new-born, 
41 
treatment  of,  41 
stone  in,  358 
Biliary  calculi  (see  Calculi,  Biliary). 
Blood,  diseases  of,  196 

Addison's  disease,  204 
haemophilia,  205 
leukaemia,  201 
pernicious  anaemia,  199 
pseudoleukemia,  202 
purpura,  207 
secondary  anaemia,  198 
simple  anaemia,  197 
in  early  infancy,  196 
Bones,  diseases  of,  324 
acute  arthritis,  324 
hip  disease,  327 
knee-joint  disease,  329 
Pott's  disease,  325 
tubercular  dactylitis,  330 
Brachial    paralysis   in   the  new-born, 

treatment  of,  34 
Bronchi,  diseases  of,  232 
Bronchitis,  acute,  232 
diagnosis  of,  233 
etiology  of,  232 
pathology  of,  232 
physical  signs  of,  233 
prognosis  of,  233 
symptoms  of,  232 
treatment  of,  233 
chronic,  234 

diagnosis  of,  234 
etiology  of,  234 
pathology  of,  234 
physical  signs  of,  234 
prognosis  of,  234 


Bronchitis,  chronic,  symptoms  of,  234 

treatment  of,  234 
fibrinous  234 

diagnosis  of,  235 

pathology  of,  235 

prognosis  of,  235 

symptoms  of,  235 

treatment  of,  235 
Broncho-pneumonia,  235 
diagnosis  of,  237 
etiology  of,  235 
pathology  of,  236 
physical  signs  of,  237 
prognosis  of,  237 
symptoms  of,  237 
treatment  of,  238 

c. 

Calculi,  biliary,  149 
diagnosis  of,  151 
etiology  of,  150 
pathology  of,  150 
prognosis  of,  151 
symptoms  of,  150 
treatment  of,  151 
renal,  267 

diagnosis  of,  268 
prognosis  of,  268 
symptoms  of,  267 
treatment  of,  268 
Capillaries,  diseases  of,  195 
Caput  succedaneum,  19 
Cardiac  neuroses,  192 
Catarrhal  croup,  222 

fever,  354 
Cephalhematoma,  treatment  of,  33 
Cerebral  abscess,  284 
diagnosis  of,  285 
etiology  of,  284 
pathology  of,  285 
prognosis  of,  286 
symptoms  of,  285 
treatment  of,  286 
hemorrhage  in  the  new-born,  32 
symptoms  of,  32 
treatment  of,  33 
palsies,  infantile,  288 
diagnosis  of,  289 
etiology  of,  288 
pathology  of,  288 
prognosis  of,  290 
symptoms  of,  289 
treatment  of,  290 
tumors,  286  . 
diagnosis  of,  2S7 


INDEX. 


37  J 


Cerebral  tumors,  etiology  of,  286 
pathology  of,  286 
prognosis  of,  288 
symptoms  of,  286 
treatment  of,  288 
Chicken-pox,  334 
Cholera  infantum,  103 
diagnosis  of,  105 
etiology  of,  104 
pathology  of,  104 
prognosis  of,  106 
symptoms  of,  104 
treatment  of,  106 
Chorea,  298 

diagnosis  of,  299 
etiology  of,  298 
pathology  of,  299 
prognosis  of,  299 
symptoms  of,  299 
treatment  of,  300 
Circulation  at  birth,  17 
Circulatory   system,   diseases  of  the, 

179 
Cirrhosis  of  liver,  147 
etiology  of,  147 
pathology  of,  147 
prognosis  of,  148 
symptoms  of,  147 
treatment  of,  148 
Cleft  palate  in  the  new-born,  39 
Club-foot,  40 
Colic,  122 

diagnosis  of,  123 
etiology  of,  122 
pathology  of,  123 
prognosis  of,  123 
symptoms  of,  123 
treatment  of,  123 
Congestion,  acute,  of  liver,  143 
symptoms  of,  143 
treatment  of,  143 
chronic,  of  liver.  1  13 
symptoms  of,  144 
treatment  of,  144 
Constipation,  124 
etiology  of,  L2 1 
prognosis  of,  125 
symptoms  of,  L25 
treatmenl  of,  125 
( Ion  vulsions,  293 
diagnosis  of,  294 
etiology  of,  293 
pathology  of,  293 
prog  Qosis  of,  29 1 
symptoms  of,  293 
treatment  of,  ~'94 


Cretinism,  291 
diagnosis  of,  292 
etiology  of,  291 
prognosis  of,  292 
symptoms  of,  291 
treatment  of,  292 
Croup,  catarrhal,  222 

membranous,  225 
Cryptorchidism  in  the  new-born,  41 

treatment  of,  41 
Cysts,  pancreatic,  152 
etiology  of,  152 
symptoms  of,  152 

r>. 

Decimal  cream,  64 

Coit's,  63 
Diabetes  insipidus,  259 
diagnosis  of,  259 
etiology  of,  259 
pathology  of,  259 
I>rognosis  of,  260 
symptoms  of,  259 
treatment  of,  260 
mellitus.  174 
diagnosis  of,  175 
etiology  of,  174 
pathology  of,  174 
prognosis  of,  175 
symptoms  of,  175 , 
treatment  of,  175 
Diarrhoea,  acute  fermental,  98 
diagnosis  of,  100 
etiology  of,  98 
pathology  of,  99 
prognosis  of,  100 
prophylaxis,  100 
symptoms  (if,  99 
treatment  of,  101 
irritative,  95 
etiology  of,  96 
pathology  of,  97 
prognosis  of,  97 
symptoms  of.  97 
treatmenl  of.  97 
Dig<  -i  ive  sj  stem,  diseases  of.  7:; 
Dilatation    of  stomach,   diagnosis   of, 
95 
i-i  iology  of,  95 
pal  hologj   of,  95 
prognosis  of,  95 
symptoms  of.  96 
treatment  of.  96 
Diphtheria,  31 1 
abnormal  cases,  '■'•  16 


372 


INDEX. 


Diphtheria,  diagnosis  of,  347 
etiology  of,  344 
incubation-period,  345 
pathology  of,  344 
prognosis  of,  347 
pseudo-,  346 
sequelae  of,  346 

symptoms  of,  345 
treatment  of,  347 

E. 

Ear,  diseases  of,  321 
acute  otitis,  321 
chronic  otitis,  323 
Eczema,  315 

diagnosis  of,  316 

etiology  of,  315 

prognosis  of,  317 

symptoms  of,  316 

treatment  of,  317 
Empyema,  250 

diagnosis  of,  251 

etiology  of,  250 

pathology  of,  250 

prognosis  of,  251 

symptoms  of,  250 

treatment  of,  251 
Endarteritis,  chronic,  193 
etiology  of,  193 
pathology  of,  193 
prognosis  of,  193 
symptoms  of,  193 
treatment  of,  193 
Endocarditis,  acute,  183 
diagnosis  of,  184 
etiology  of,  183 
pathology  of,  183 
physical  signs  of,  184 
prognosis  of,  184 
symptoms  of,  183 
treatment  of,  185 

chronic,  186 

diagnosis  of,  189 
etiology  of,  186 
pathology  of,  187 
physical  signs  of,  188 
prognosis  of,  189 
symptoms  of,  187 
treatment  of,  190 

malignant,  185 
diagnosis  of,  186 
etiology  of,  185 
pathology  of,  185 
physical  signs  of,  186 
prognosis  of,  186 


Endocarditis,  malignant,  symptoms  of, 
185 
treatment  of,  186 
Enteritis,  chronic  tubercular,  118 
diagnosis  of,  118 
etiology  of,  118 
pathology  of,  118 
prognosis  of,  119 
symptoms  of,  118 
treatment  of,  119 
Entero-colitis,  acute,  111 
diagnosis  of,  114 
etiology  of,  111 
pathology  of,  111 
prognosis  of,  114 
symptoms  of,  113 
treatment  of,  114 
chronic,  116 

diagnosis  of,  117 
etiology  of,  116 
pathology  of,  116 
prognosis  of,  117 
symptoms  of,  116 
treatment  of,  117 
Enuresis,  257 
diagnosis  of,  257 
etiology  of,  257 
prognosis  of,  257 
symptoms  of,  257 
treatment  of,  257 
Epilepsy,  296 
diagnosis  of,  297 
etiology  of,  296 
pathology  of,  296 
prognosis  of,  298 
symptoms  of,  296 
treatment  of,  298 
Epispadias  in  the  new-born,  40 
Epistaxis,  210 
diagnosis  of,  211 
etiology  of,  210 
pathology  of,  210 
prognosis  of,  211 
symptoms  of,  210 
treatment  of,  211 
Erb's  paralysis,  34 
Erysipelas,  342 

complications  of,  343 
diagnosis  of,  343 
etiology  of,  342 
pathology  of,  342 
prognosis  of,  343 
symptoms  of,  343 
treatment  of,  343 
Eyes  at  birth,  21 
infection  of,  21 


INDEX. 


373 


F. 

Facial  paralysis  in   new-born, 

ment  of,  34 
Fatty  liver,  145 

symptoms  of,  146 

treatment  of,  146 
Fissura  ani,  137 

etiology  of,  137 

symptoms  of,  138 

treatment  of,  138 
Fistula  in  ano,  138 

etiology  of,  139 

symptoms  of,  139 

treatment  of,  139 
congenital,  of  neck,  88 
Fontanelles  at  birth,  19 
Friedreich's  ataxia,  276 

diagnosis  of,  277 

etiology  of,  276 

pathology  of,  277 

prognosis  of,  277 

symptoms  of,  277 

treatment  of,  277 
Functional  albuminuria,  260 

diagnosis  of,  260 

etiology  of,  260 

pathology  of,  260 

prognosis  of,  260 

symptoms  of,  260 

treatment  of,  260 
Furunculosis,  313 
diagnosis  of,  314 
etiology  of,  313 
symptoms  of,  313 
treatment  of,  314 

G. 

Gastritis,  acute,  91 

etiology  of,  91 

pathology  of,  91 

prognosis  of,  92 

symptoms  of,  91 

I  reatment  of,  92 
chronic,  93 

etiology  of,  93 

pathology  of,  94 

prognosis  of,  !»l 

symptoms  of,  91 

t  real  men  I  of,  95 
Gasl  ro-duodenil  is,  92 
etiology  of,  92 
pathology  of,  !•:'• 
prognosis  of,  93 


treat- 


Gastro-duodenitis,  symptoms  of,  93 

treatment  of,  93 
Genito-urinary    system,    diseases    of, 
257 
acute  degeneration  of  kidneys, 
261 
diffuse  nephritis,  263 
exudative  nephritis,  261 
balanitis,  270 

chronic  diffuse  nephritis,  264 
diabetes  insipidus,  259 
enuresis,  257 

functional  albuminuria,  260 
perinephritis,  268 
phimosis,  269 
polyuria,  259 
pyelitis,  266 
renal  calculi,  267 
tumors  of  kidney,  265 
vesical  calculus,  258 
vulvo-vaginitis,  270 
German  measles,  337 

H. 

Hemoglobinuria,  epidemic,  35 
Haemophilia,  205 
diagnosis  of,  206 
etiology  of,  205 
pathology  of,  206 
prognosis  of,  206 
symptoms  of,  206 
treatment  of,  206 
Hare-lip  in  the  new-born,  39 
Hay  asthma,  219 
fever,  219 
diagnosis  of,  220 
etiology  of,  219 
pathology  of,  219 
prognosis  of,  220 
symptoms  of,  219 
treatment  of,  220 
Head  at  birth,  19 
Headaches,  302 
diagnosis  of,  302 
etiology  of,  302 
pathology  of,  302 
symptoms  of,  302 
treatment  of,  302 
Hearing,  normal  development  of,  28 
Heart  disease,  congenital,  179 
diagnosis  <>r,  180 
etiology  of,  179 
pathology  of,  I T«> 
prognosis  of,  l  B0 
symptoms  of,  180 


374 


INDEX. 


Heart  disease,  treatment  of,  180 
and  pericardium,  diseases  of,  179 
acute  endocarditis,  183 
myocarditis,  191 
pericarditis,  181 
cardiac  neuroses,  192 
chronic  endocarditis,  186 

pericarditis,  182 
malignant  endocarditis,  185 
Hemorrhoids,  137 
etiology  of,  137 
treatment  of,  137 
Hepatitis,  suppurative,  144 
diagnosis  of,  145 
etiology  of,  144 
prognosis  of,  145 
symptoms  of,  145 
treatment  of,  145 
Hernia,  umbilical,  in  the  new-born,  37 
Hip  disease,  327 

diagnosis  of,  329 
etiology  of,  327 
pathology  of,  327 
prognosis  of,  329 
symptoms  of,  328 
treatment  of,  329 
Hives,  318 

Hodgkin's  disease,  202 
Hydatids  of  liver,  148 
diagnosis  of,  149 
etiology  of,  148 
pathology  of,  148 
physical  signs  of,  149 
prognosis  of,  149 
symptoms  of,  149 
treatment  of,  149 
Hydrocephalus,  283 
diagnosis  of,  284 
etiology  of,  283 
pathology  of,  283 
prognosis  of,  284 
symptoms  of,  283 
treatment  of,  284 
Hypospadias  in  the  new-born,  40 
Hysteria,  300 
diagnosis  of,  301 
etiology  of,  300 
pathology  of,  300 
prognosis  of,  301 
symptoms  of,  300 
treatment  of,  301 


Ichthyosis,  311 
etiology  of,  311 


Ichthyosis,  pathology  of,  311 
prognosis  of,  312 
symptoms  of,  311 
treatment  of,  312 
Icterus,  31 

Idiocy  and  imbecility,  290 
diagnosis  of,  291 
difference  between,  290 
prognosis  of,  291 
symptoms  of,  290 
treatment  of,  291 
Imperforate  rectum,  40 
Impetigo  contagiosa,  314 
diagnosis  of,  315 
etiology  of,  314 
prognosis  of,  315 
symptoms  of,  314 
treatment  of,  315 
Indigestion,  acute  gastric,  90 
etiology  of,  90 
pathology  of,  90 
symptoms  of,  90 
treatment  of,  91 
chronic  intestinal,  107 
diagnosis  of,  109 
etiology  of,  107 
pathology  of,  108 
prognosis  of,  109 
symptoms  of,  108 
treatment  of,  109 
Infant  at  birth,  17 
abdomen  of,  19 
bathing  of,  20 
circulation,  17 
clothing  of,  21 
examination  of,  for  abnormalities, 

21 
eyes  of,  21 
food  of,  22 
head  of,  19 
intestines  of,  19 
kidneys  of,  20 
length  of,  18 
mouth  of,  21 

premature  and  delicate,  22 
respiration,  17 
skin,  18 
sleep  of,  22 
temperature,  18 
thorax  of,  19 
umbilical  cord  of,  20 
weight  of,  19 
feeding  of,  43 
artificial,  58 

care  of  bottles  and  nipples,  62 
home  modifications,  63 


INDEX. 


375 


Infant,    feeding    of,    artificial,    prepa- 
ration of  cows'  milk  for,  59 

rules  for,  60 
during  fourth  year,  72 

second  year,  71 

third  year,  72 
mixed,  53 
foods,  69 

barley-water,  71 
beef-juice,  71 
broths,  71 
egg-water,  71 
malted  milk,  69 
Mellins'  food,  69 
oatmeal-water,  71 
peptonized  milk,  70 
rice-water,  71 
scraped  beef,  71 
whey,  70 
new-born,  diseases  of,  31 

asphyxia,  31 

cephalhematoma,  33 

cerebral  hemorrhage,  32 

cleft  palate,  39 

club-foot,  40 

cryptorchidism,  41 

epidemic  hemoglobinuria,  35 

epispadias,  40 

extrophy  of  bladder,  41 

granuloma  of  umbilicus,  36 

hare-lip,  39 

hydrocephalus,  38 

hypospadias,  40 

icterus,  31 

imperforate  rectum,  40 

mastitis,  37 

rnelrena,  36 

meningocele,  38 

obstetrical  paralysis,  33 

ophthalmia,  32 

pemphigus,  '■'><> 

sclerema,  37 

sepsis,  34 

spina  bifida,  39 

tetanus,  ::•""> 

umbilical  hernia,  37 
normal  <le\  elopmenl  of,  24 

abdomen  in,  25 

dciil  il  ion  in,  26 

feces  in,  28 

head  in.  25 

hearing  in.  28 

height  in.  -.'I 

muscular  acts  in,  25 

pulse  in.   .''I 

respiration  in,  26 


Infant,  normal  development  of  sight 
in,  28 
smell  in,  29 
speech  in,  29 
taste  in,  29 
temperature  in,  26 
thorax  in,  25 
touch  in,  28 
urine  in,  27 
weaning  of,  54 
Infectious  diseases,  332 
Influenza,  epidemic,  354 
Intermittent  fever,  361 
Intestinal  obstruction,  126 

parasites,  131 
Intestines  at  birth,  19 
diseases  of,  96 
acute  entero -colitis,  111 
fermental  diarrhoea,  98 
irritative  diarrhoea,  96 
appendicitis,  119 
cholera  infantum,  103 
chronic  entero-colitis,  116 
intestinal  indigestion,  107 
tubercular  enteritis,  118 
colic,  122 
constipation,  124 
intestinal  obstruction,  126 

parasites,  131 
intussusception,  127 
pin-worms,  132 
round  worms,  131 
tapeworms,  134 
Intussusception,  127 
diagnosis  of,  129 
etiology  of,  128 
pathology  of,  128 
prognosis  of,  129 
symptoms  of,  128 
treatment  of,  129 
varieties  of,  127 
Ischio-rectal  abscess,  138 
etiology  of,  138 
symptoms  of,  138 
treatment  of,  138 


J. 


Jaundice-,  I  1 1 
etiology  of,  1  II 
physical  signs  of,  142 
prognosis  of,  l  12 
symptoms  of,  1  1 1 
I  reatment  of,  1  12 


376 


INDEX. 


K. 

Kidneys,  acute  degeneration  of,  261 

etiology  of,  261 

pathology  of,  261 

prognosis  of,  261 

symptoms  of,  261 

treatment  of,  261 
at  birth,  20 
tumors  of,  265 
diagnosis  of,  266 
pathology  of,  266 
prognosis  of,  266 
symptoms  of,  266 
treatment  of,  266 
Knee-joint  disease,  329 
diagnosis  of,  330 
etiology  of,  329 
pathology  of,  329 
prognosis  of,  330 
symptoms  of,  329 
treatment  of,  330 

L. 

La  grippe,  354 
complications,  355 
diagnosis  of,  355 
etiology  of,  354 
incubation -period  of,  354 
pathology  of,  354 
prognosis  of,  355 
symptoms  of,  354 
treatment  of,  356 
Laryngitis,  acute  catarrhal,  222 
diagnosis  of,  223 
etiology  of,  222 
pathology  of,  222, 
prognosis  of,  224 
symptoms  of,  222 
treatment  of,  224 
chronic,  228 

diagnosis  of,  229 
etiology  of,  229 
pathology  of,  229 
prognosis  of,  229 
symptoms  of,  229 
treatment  of,  229 
membranous,  225 
diagnosis  of,  226 
etiology  of,  225 
intubation  in,  227 
pathology  of,  225 
prognosis  of,  226 
symptoms  of,  225 
treatment  of,  226 
spasmodic,  220 


Laryngitis,    spasmodic,   diagnosis   of, 
221 
etiology  of,  220 
pathology  of,  221 
prognosis  of,  221 
symptoms  of,  221 
treatment  of,  221 
Larynx,  diseases  of,  220 

acute  catarrhal  laryngitis,  222 
chronic  laryngitis,  228 
membranous  laryngitis,  225 
oedema  glottidis,  231 
spasmodic  laryngitis,  220 
foreign  bodies  in,  231 
diagnosis  of,  231 
prognosis  of,  231 
symptoms  of,  231 
treatment  of,  232 
papilloma  of,  230 
diagnosis  of,  230 
prognosis  of,  230 
symptoms  of,  230 
treatment  of,  230 
Length  at  birth,  18 
Lentigo,  311 
etiology  of,  311 
treatment  of,  311 
Leukaemia,  201 
diagnosis  of,  202 
etiology  of,  201 
pathology  of,  201 
prognosis  of,  202 
symptoms  of,  202 
treatment  of,  202 
Liver,  acute  congestion  of,  etiology  of, 
143 
chronic  congestion  of,  diagnosis  of, 
144 
etiology  of,  143 
pathology  of,  144 
prognosis  of,  144 
diseases  of,  141 
acute  congestion,  143 
amyloid,  146 
biliary  calculi,  149 
chronic  congestion,  143 
cirrhosis  of,  147 
hydatids  of,  148 
jaundice,  141 
suppurative  hepatitis,  144 
functional  disorders  of,  142 
etiology  of,  142 
fatty,  145 
Lungs,  diseases  of,  232 
Lymph-nodes,  diseases  of,  306 
acute  adenitis,  306 


INDEX. 


377 


Lymph-nodes,    diseases    of,    chronic 
adenitis,  307 
tubercular  adenitis,  308 

M. 

Malaria,  360 

diagnosis  of,  362 
etiology  of,  360 
incubation-period,  361 
prognosis  of,  362 
treatment  of,  362 
varieties  of,  361 
Malnutrition,  161 
diagnosis  of,  162 
etiology  of,  161 
pathology  of,  161 
prognosis  of,  162 
symptoms  of,  161 
treatment  of,  162 
Malted  milk  as  an  infant  food,  69 
Marasmus,  163 
diagnosis  of,  165 
etiology  of,  163 
pathology  of,  164 
prognosis  of,  165 
symptoms  of,  164 
treatment  of,  165 
Mastitis  in  the  new-born,  37 
symptoms  of.  37 
treatment  of,  37 
Masturbation,  305 

treatment  of,  305 
Maternal  nursing,  rules  for,  46 

contraindications  for,  47 
Measles,  335 

abnormal  cases  of,  336 
complications  of,  336 
diagnosis  of,   336 
etiology  of,  335 
incubation-period  of,  335 
prognosis  of,  336 
symptoms  of,  335 
treatment  of,  336 
Melsena  in  the  new-born,  35 

i  reatmenl  of,  '■'■<> 
Meningitis,  acute.  279 
diagnosis  of,  280 
etiology  of,  279 
pathology  of,  280 
prognosis  of,  281 
Bymptome  of,  280 
treatmenl  of,  281 
tubercular,  281 
diagii'i- ;      -     -'-  ' 
etiology  of,  281 


Meningitis,  tubercular,  pathology  of, 
281 
prognosis  of,  283 
symptoms  of,  282 
treatment  of,  283 
Meningocele,  of  the  new-born,  38 
symptoms  of,  39 
treatment  of,  39 
Mellins'  food,  69 
Middle  ear,  inflammation  of,  321 
Miliaria,  312 
diagnosis  of,  313 
etiology  of,  312 
pathology  of,  312 
symptoms  of,  313 
treatment  of,  313 
Milk,  age  of,  52 
condensed,  67 
as  a  food,  68 
cows',  54 
care  of,  56 

chemical  composition  of,  55 
comparison  of,  with  woman's,  55 
fat  in,  55 
germ-life  in,  56 
method  of  examination  of,  67 
pasteurization  of,  57 

method  of,  58 
proteids  of,  55 
salts  in,  56 
sterilization  of,  57 

methods  of,  57 
sugar  in,  55 
laboratories,  62 

advantages  of,  63 
malted,  69 
peptonized,  70 

quantity  of,  causes  affecting,  53 
saccharated  skimmed,  64 
woman's,  43 

characteristics,  43 
chemical  composition,  43 
clinical  analysis  of,  l!» 

Holt's  test,  49 
colostrum,  45 
fat  in,  44 

ingredients  in,  changing  of,  50 
proteids  of,  43 
quantity  of,  daily,  45 
salts  in,  44 
sugar  in,  44 
water  in,  44 
Mouth  at  birth.  :.'! 
diseases  of,  73 

adhresia  linguae,  79 
alveolar  abscess,  80 


378 


INDEX. 


Mouth,  diseases  of,  catarrhal   stoma- 
titis, 73 
croupous  stomatitis,  73 
follicular  stomatitis,  74 
gangrenous  stomatitis,  77 
ranula,  79 
thrush,  76 

ulcerative  stomatitis,  75 
Mumps,  353 

complications  of,  352 
diagnosis  of,  353 
etiology  of,  353 
incubation-period  of,  353 
pathology  of,  353 
prognosis  of,  354 
symptoms  of,  353 
treatment  of,  354 
Muscular  atrophy,  progressive,  277 
diagnosis  of,  278 
pathology  of,  277 
prognosis  of,  278 
symptoms  of,  277 
treatment  of,  278 
paralysis,  pseudo-hypertrophic,  278 
diagnosis  of,  279 
etiology  of,  278 
pathology  of,  278 
prognosis  of,  279 
symptoms  of,  278 
treatment  of,  279 
Myelitis,  transverse,  275 
diagnosis  of,  276 
etiology  of,  275 
pathology  of,  275 
prognosis  of,  276 
symptoms  of,  276 
treatment  of,  276 
Myocarditis,  acute,  191 
diagnosis  of,  191 
etiology  of,  191 
pathology  of,  191 
prognosis  of,  191 
symptoms  of,  191 
treatment  of,  191 

N. 

Nsevus,  195 

diagnosis  of,  196 

etiology  of,  195 

pathology  of,  195 

prognosis  of,  196 

symptoms  of,  195 

treatment  of,  196 
Nasal  polypi,  218 
diagnosis  of,  219 


Nasal  polypi,  etiology  of,  218 
pathology  of,  218 
prognosis  of,  219 
symptoms  of,  218 
treatment  of,  219 
Naso-pharynx,  adenoids  of,  83 
etiology  of,  83 
pathology  of,  83 
prognosis  of,  84 
symptoms  of,  83 
treatment  of,  84 
Neck,  congenital  fistula  of,  88 
Nephritis,  acute  diffuse,  263 

diagnosis  of,  263 

etiology  of,  263 

pathology  of,  263 

prognosis  of,  263 

symptoms  of,  263 

treatment  of,  263 
exudative,  261 

diagnosis  of,  262 

etiology  of,  261 

pathology  of,  261 

prognosis  of,  262 

symptoms  of,  262 

treatment  of,  262 
chronic  diffuse,  264 

diagnosis  of,  261 

etiology  of,  264 

pathology  of,  264 

prognosis  of,  265 

symptoms  of,  264 

treatment  of,  265 
Nervous  system,  diseases  of,  272 

acute  anterior  poliomyelitis,  273 
meningitis,  279 

bad  habits,  305 

cerebral  abscess,  284 
palsies,  infantile,  288 
tumors,  286 

chorea,  298 

convulsions,  293 

cretinism,  291 

epilepsy,  296 

Friedreich's  ataxia,  276 

headaches,  302 

hydrocephalus,  283 

hysteria,  300 

idiocy  and  imbecility,  290 

peripheral  neuritis,  272 

progressive    muscular   atrophy, 
277 

pseudo-hypertrophic    muscular 
paralysis,  278 

sleep-disorders,  304 

speech-disorders,  303 


INDEX. 


379 


■Nervous  system,  tetany,  295 

transverse  myelitis,  275 
tubercular  meningitis,  281 
Nettle-rash,  318 
Neuritis,  peripheral,  272 

diagnosis  of,  272 

etiology  of,  272 

pathology  of,  272 

prognosis  of,  273 

symptoms  of,  272 

treatment  of,  273 
Neuroses,  cardiac,  192 

diagnosis  of,  192 

etiology  of,  192 

pathology  of,  192 

prognosis  of,  192 

symptoms  of,  192 

treatment  of,  193 
Nose,  diseases  of,  210 

acute  rhinitis,  211 

atrophic  rhinitis,  215 

chronic  rhinitis,  213 

epistaxis,  210 

hay  fever,  219 

hypertrophic  rhinitis,  214 

membranous  rhinitis,  216 

nasal  polypi,  218 

syphilitic  rhinitis,  217 
Nursing  women,  diet  for,  49 

drugs  for,  50 

exercise  for,  50 
Nutrition,  disorders  of,  161 

acute  rheumatism,  175 

diabetes  mellitus,  174 

malnutrition,  161 

marasmus,  163 

rachitis,  168 

scorbutus,  166 

o. 

(Edema  glottidis,  231 

diagnosis  of,  231 

el  iology  of,  231 

pathology  of,  231 

prognosis  of,  231 

symptoms  of,  231 

treatmenl  of,  231 
<  Ksopliagitis,  acute,  SS 

etiology  of.  ss 

symptoms  of,  88 

treatmenl  of,  88 
Ophthalmia,  32 

symptoms  of,  '■'•'' 

t  reatmeni  of,  32 
Otitis,  acute,  321 


Otitis,  acute,  diagnosis  of,  322 

etiology  of,  321 

pathology  of,  321 

prognosis  of,  322 

symptoms  of,  321 

treatment  of,  322 
chronic,  323 

diagnosis  of,  323 

etiology  of,  323 

pathology  of,  323 

prognosis  of,  323 

symptoms  of,  323 

treatment  of,  323 
Otorrhcea,  chronic,  323 

P. 

Pancreas,  diseases  of,  152 
Pemphigus  in  the  new-born,  36 
Pericarditis,  acute,  181 
diagnosis  of,  181 
etiology  of,  181 
pathology  of,  181 
physical  signs,  181 
prognosis  of,  181 
symptoms  of,  181 
treatment  of,  182 
chronic,  182 

pathology  of,  182 
physical  signs  of,  183 
prognosis  of,  183 
symptoms  of,  182 
treatment  of,  183 
Perinephritis,  268 
diagnosis  of.  269 
etiology  of,  268 
pathology  of,  268 
prognosis  of,  269 
symptoms  of,  269 
treatment  of,  269 
Peritoneum,  diseases  of,  153 
acute  peritonitis,  153 
chronic  peritonitis,  157 
tubercular  peritonitis,  158 
Peritonitis,  acute,  153 
diagnosis  of,   155 
etiology  of,  153 
pathology  of,  154 
prognosis  of,  155 
symptoms  of,  154 
treatment  of,  155 
chronic,  157 

diagnosis   of,    157 
el  iology  of,  157 
pathology  of,  157 
prognosis  of,  158 


380 


INDEX. 


Peritonitis,  chronic,  symptoms  of,  157 

treatment  of,  158 
tubercular,  158 

etiology  of,  158 

pathology  of,  158 

prognosis  of,  160 

symptoms  of,  159 

treatment  of,  160 
Peritonsillar  abscess,  85 

etiology  of,  85 

pathology  of,  86 

prognosis  of,  86 

symptoms  of,  86 

treatment  of,  86 
Pharyngitis,  acute,  80 

diagnosis  of,  81 

etiology  of,  80 

pathology  of,  80 

symptoms  of,  80 

treatment  of,  81 
local,  81 
chronic,  81 

treatment  of,  81 
Phimosis,  269 
symptoms  of,  270 
treatment  of,  270 
Phlebitis,  acute,  194 

diagnosis  of,  194 

etiology  of,  194 

pathology  of,  194 

prognosis  of,  194 

symptoms  of,  194 

treatment  of,  194 
Pleura,  diseases  of,  232 
Pleurisy,  dry,  247 

diagnosis  of,  247 

etiology  of,  247 

pathology  of,  247 

physical  signs  of,  247 

prognosis  of,  247 

symptoms  of,  247 

treatment  of,  248 
with  effusion,  248 

diagnosis  of,  249 

etiology  of,  248 

pathology  of,  248 

physical  signs  of,  249 

prognosis  of,  249 

symptoms  of,  248 

treatment  of,  249 
Pneumonia,  broncho-,  235 
lobar,  239 

diagnosis  of,  241 

etiology  of,  239 

pathology  of,  239 

physical  signs  of,  240 


Pneumonia,  lobar,  prognosis  of,  241 

symptoms  of,  240 

treatment  of,  241 
interstitial,  241 

diagnosis  of,  242 

etiology  of,  241 

pathology  of,  242 

physical  signs  of,  242 

prognosis  of,  242 

symptoms  of,  242 

treatment  of,  242 
Poliomyelitis,  acute  anterior,  273 

diagnosis  of,  274 

etiology  of,  273 

pathology  of,  274 

prognosis  of,  275 

symptoms  of,  274 

treatment  of,  275 
Polypus  recti,  140 

pathology  of,  140 

symptoms  of,  140 

treatment  of,  140 
Pott's  disease,  325 

diagnosis  of,  326 

etiology  of,  325 

pathology  of,  325 

prognosis  of,  326 

symptoms  of,  325 

treatment  of,  327 
Proctitis,  acute,  139 

etiology  of,  139 

symptoms  of,  139 

treatment  of,  140 
Prolapsus  ani,  136 

diagnosis  of,  136 

etiology  of,  136 

symptoms  of,  136 

treatment  of,  136 
Pruritus  ani,  135 

etiology  of,  135 

treatment  of,  136 
Pseudoleukemia,  202 
diagnosis  of,  204 
etiology  of,  203 
pathology  of,  203 
prognosis  of,  204 
symptoms  of,  203 
treatment  of,  204 
Pulmonary  atelectasis,  246 

diagnosis  of,  247 

etiology  of,  246 

pathology  of,  246 

physical  signs,  246 

prognosis  of,  247 

symptoms  of,  246 

treatment  of,  247 


INDEX. 


381 


Pulmonary  emphysema,  243 

diagnosis  of,  243 

etiology  of,  243 

pathology  of,  242 

physical  signs  of,  243 

prognosis  of,  243 

symptoms  of,  243 

treatment  of,  243 
gangrene,  245 

diagnosis  of,  245 

etiology  of,  245 

pathology  of,  245 

physical  signs  of,  245 

prognosis  of,  246 

symptoms  of,  245 

treatment  of,  246 
Pulse  at  birth,  18 
Purpura,  207 
diagnosis  of,  208 
etiology  of,  207 
haemorrhagica,  208 
pathology  of,  207 
prognosis  of,  209 
rheumatica,  208 
symptoms  of,  207 
treatment  of,  209 
Pyelitis,  266 

diagnosis  of,  267 
etiology  of,  266 
pathology  of,  266 
prognosis  of,  267 
symptoms  of,  267 
treatment  of,  267 

R. 

Rachitis,  168 
diagnosis  of,  173 
etiology  of,  168 
pathology  of,  169 
prognosis  of,  173 
symptoms  of,  170 
treatment  of,  173 
Banula,  7!> 

symptoms  of,  79 
i  reatment  of,  79 
Rectum,  diseases  of,  135 
acute  proctitis,  139 
fissura  ani,  137 
fistula  in  aim,  138 
hemorrhoids,  137 
ischio-rectal  abscess,  138 
prolapsus  ani,  L36 
pruritus  ani.  135 
imperforate,  40 
Remittent  fever,  :'.';i 
R<  i j . 1 1  calculi    see  <  'alcitli,  Ilcnal). 


Respiration  at  birth,  17 

aids  to,  17 

how  established,  17 

rate  of,  17 
Respiratory  system,  diseases  of,  210 
Retro-cesophageal  abscess,  89 

etiology  of,  89 

symptoms  of,  89 
Retro-pharyngeal  abscess,  81 

diagnosis  of,  82 

etiology  of,  82 

pathology  of,  82 

prognosis  of,  82 

treatment  of,  82 
Rheumatism,  acute,  175 

diagnosis  of,  177 

etiology  of,  175 

pathology  of,  176 

prognosis  of,  177 

symptoms  of,  176 

treatment  of,  177 
Rhinitis,  acute,  211 

diagnosis  of,  212 

etiology  of,  211 

pathology  of,  212 

prognosis  of,  212 

symptoms  of,  212 

treatment  of,  212 
atropine,  215 

diagnosis  of,  215 

etiology  of,  215 

pathology  of,  215 

prognosis  of,  216 

symptoms  of,  215 

treatment  of,  216 
chronic,  213 

diagnosis  of,  213 

etiology  of,  213 

prognosis  of,  213 

symptoms  of,  213 

treatment  of,  214 
hypertrophic,  214 

diagnosis  of,  214 

etiology  of,  214 

pathology  of,  214 

prognosis  of,  215 

symptoms  of.  214 

treatment  of,  215 
membranous,  216 

diagnosis  of,  217 

etiology  of,  •.'in 

pathology  of,  216 

prognosis  of,  217 

symptoms  of,  216 

treatment  of,  217 
syphilitic,  217 


382 


INDEX. 


Ehinitis,  syphilitic,  diagnosis  of,  218 
etiology  of,  217 
pathology  of,  217 
prognosis  of,  218 
symptoms  of,  218 
treatment  of,  218 
King-worm,  319 
Rose  cold,  219 
Rotheln,  337 
diagnosis  of,  337 
etiology  of,  337 
incubation-period  of,  337 
prognosis  of,  337 
symptoms  of,  337 
treatment  of,  337 
Rubella,  337 

S. 

Scabies,  318 

diagnosis  of,  319 
etiology  of,  318 
pathology  of,  319 
prognosis  of,  319 
symptoms  of,  319 
treatment  of,  319 
Scarlatina,  337  < 
Scarlet  fever,  337 

complications  of,  339 
diagnosis  of,  340 
etiology  of,  338 
incubation-period  of,  338 
patbology  of,  338 
prognosis  of,  341 
symptoms  of,  338 
treatment  of,  341 
Sclerema  in  the  new-born,  37 

treatment  of,  37 
Scorbutus,  166 
diagnosis  of,  167 
etiology  of,  166 
pathology  of,  166 
prognosis  of,  168 
symptoms  of,  166 
treatment  of,  168 
Seborrhcea,  312 
etiology  of,  312 
symptoms  of,  312 
treatment  of,  312 
Sepsis  in  the  new-born,  34 
symptoms  of,  34 
treatment  of,  34 
Sight,  normal  development  of,  28 
Skin  at  birth,  18 

desquamation  of,  18 
lanugo,  18 


Skin  at  birth,  vernix  caseosa,  18 
diseases  of,  311 
eczema,  31") 
furunculosis,  313 
ichthyosis,  311 
impetigo  contagiosa,  314 
lentigo,  311 
miliaria,  312 
scabies,  318 
seborrhcea,  312 
tinea  trichopliytina,  319 
urticaria,  31« 
Sleep-disorders,  304 
diagnosis  of,  304 
etiology  of,  304 
prognosis  of,  304 
symptoms  of,  304 
treatment  of,  304 
Smell,  normal  development  of,  29 
Spasmodic  contractions,  293 
Speech-disorders,  303 
varieties  of,  303 
late  development,  303 
lisping,  303 
stuttering,  303 
aphasia,  303 
Speech,  normal  development  of,  29 
Spina  bifida,  39 

symptoms  of,  39 

treatment  of,  39 

Spleen,  diseases  of,  152 

enlargement  of,  153 

treatment  of,  153 

Stomach,  diseases  of,  90 

acute  gastric  indigestion,  90 
acute  gastritis,  91 
chronic  gastritis,  93 
dilatation  of,  95 

gastro-duodenitis,  92 
ulcer  of,  96 
Stomatitis,  croupous,  78 
etiology  of,  78 
pathology  of,  79 
symptoms  of,  79 
treatment  of,  79 
catarrhal,  73 
etiology  of,  73 
pathology  of,  73 
prognosis  of,  73 
symptoms  of,  73 
treatment  of,  73 
follicular,  74 

etiology  of,  74 

•  pathology  of,  74 

prognosis  of,  74 

symptoms  of,  74 


INDEX. 


383 


Stomatitis,  follicular,  treatment  of,  74 
gangrenous,  77 
etiology  of,  77 
pathology  of,  77 
prognosis  of,  78 
symptoms  of,  77 
treatment  of,  78 
ulcerative,  75 
etiology  of,  75 
pathology  of,  75 
prognosis  of,  75 
symptoms  of,  75 
treatment  of,  75 
Strabismus  in  infant  at  birth,  21 
Sucking,  25 
Sugar  solution,  65 
Syphilis,  363 
diagnosis  of,  369 
etiology  of,  363 
forms  of,  363 
pathology  of,  364 
prognosis  of,  366 
symptoms  of,  364 
treatment  of,  367 

T. 

Taste,  normal  development  of,  29 
Teeth,  early,  27 
milk,  26 
second,  27 
Temperature  at  birth,  18 
Tetanus  in  the  new-born,  35 
symptoms  of,  35 
treatment  of,  35 
Tetany,  295 

diagnosis  of,  296 
etiology  of,  295 
pathology  of,  295 
prognosis  of,  296 
symptoms  of,  295 
treatment  of,  296 
Thorax  at  birth,  19 
Throat,  diseases  of,  80 

acute  follicular  tonsillitis,  84 
oesophagitis,  88 
pharyngitis,  80 
adenoids  of  naso-pharynx,  83 
chronic  pharyngitis,  81 

tonsillil  is,  B7 
congenital  fistula  of  neck,  38 
peritonsillar  abscess,  86 
retro-oesophageal  abscess,  89 
rel ro-pharyngeal  abscess,  -l 
foreign  bodies  in,  B9 
Thrush,  76 


Thrush,  etiology  of,  76 
pathology  of,  76 
prognosis  of,  77 
symptoms  of,  76 
treatment  of,  77 
Tinea  trichophytina,  319 
diagnosis  of,  320 
etiology  of,  319 
prognosis  of,  320 
symptoms  of,  319 
treatment  of,  320 
Tonsillitis,  acute  follicular,  84 
etiology  of,  84 
pathology  of,  84 
prognosis  of,  85 
symptoms  of,  85 
treatment  of,  85 
chronic,  87 
etiology  of,  87 
pathology  of,  87 
symptoms  of,  87 
treatment  of,  87 
Tonsils,  hypertrophy  of,  97 
Touch,  normal  development  of,  28 
Treatment  of  acute  adenitis,  307 
anterior  poliomyelitis,  275 
arthritis,  325 
bronchitis,  233 
catarrhal  laryngitis,  224 
congestion  of  liver,  143 
degeneration  of  kidneys,  261 
diffuse  nephritis,  263 
endocarditis,  185 
entero-colitis,  114 
exudative  nephritis,  262 
fermental  diarrhoea,  101 
follicular  tonsillitis,  85 
gastric  indigestion.  90 
gastritis,  92 
irritative  diarrhoea,  97 
meningitis,  281 
myocarditis,  191 
oesophagitis,  88 
otitis,  322 
pericarditis,  182 
peritonitis,  155 
pharyngitis,  81 
phlebitis,  191 
proctitis,  1  10 

pulmonary  tuberculosis,  253 
rheumal  ism,  177 
rhiiiii  is,  •.'I'.' 
ill'  Addison's  disease,  205 
hi'  adenoids  of  naso-pharynx,  84 
nl'  adhsesia  linguse,  79 
ill'  amyloid  liver,  1 16 


384 


INDEX. 


Treatment  of  appendicitis,  122 
of  asphyxia  in  the  new-born,  31 
of  asthma,  244 
of  atrophic  rhinitis,  216 
of  balanitis,  270 
of  biliary  calculi,  151 
of  brachial  paralysis   in   the   new- 
born, 34 
of  broncho-pneumonia,  238 
of  cardiac  neuroses,  193 
of  catarrhal  stomatitis,  73 
of  cephalliEematonia,  33 
of  cerebral  abscess,  286 

hemorrhage  in  the  new-born,  33 

palsies,  infantile,  290 

tumors,  288 
of  cholera  infantum,  106 
of  chorea,  300 
of  chronic  adenitis,  308 

bronchitis,  234 

congestion  of  liver,  144 

diffuse  nephritis,  265 

endarteritis,  193 

endocarditis,  190 

entero-colitis,  117 

gastritis,  95 

intestinal  indigestion,  109 

laryngitis,  229 

otitis,  323 

pericarditis,  183 

peritonitis,  158 

pharyngitis,  81 

pulmonary  tuberculosis,  255 

rhinitis,  214 

tonsillitis,  87 

tubercular  enteritis,  119 
of  cirrhosis  of  liver,  148 
of  cleft  palate,  39 
of  colic,  123 
of  constipation,  125 
of  convulsions,  294 
of  cretinism,  292 
of  croupous  stomatitis,  79 
of  cryptorchidism,  41 
of  diabetes  insipidus,  260 

of  mellitus,  175 
of  dilatation  of  stomach,  96 
of  diphtheria,  347 
of  dry  pleurisy,  248 
of  eczema,  317 
of  empyema,  251 
of  enlargement  of  spleen,  153 
of  enuresis,  257 
of  epilepsy,  298 
of  epistaxis,  211 
of  erysipelas,  343 


Treatment  of  extrophy  of  bladder  in 

the  new-born,   41 
of  facial  paralysis  in  the  new-born, 

34 
of  fatty  liver,  146 
of  fibrinous  bronchitis,  235 
of  fissura  ani,  138 
of  fistula  in  ano,  139 
of  follicular  stomatitis,  74 
of  foreign  bodies  in  larynx,  232 
of  Friedreich's  ataxia,  277 
of  functional  albuminuria,  260 

disorders  of  liver,  143 
of  fiminculosis,  314 
of  gangrenous  stomatitis,  78 
of  gastro-duodenitis,  93 
of  granuloma  of  umbilicus  in  the 

new-born,  37 
of  haemophilia,  206 
of  hare-lip,  39 
of  hay  fever,  220 
of  headache,  302 
of  hemorrhoids,  137 
of  hip  disease,  329 
of  hydatids  of  liver,  149 
of  hydrocephalus,  38,  284 
of  hypertrophic  rhinitis,  215 
of  hysteria,  301 
of  ichthyosis,  312 
of  impetigo  contagiosa,  315 
of  interstitial  pneumonia,  242 
of  intussusception,  129 
of  ischio-rectal  abscess,  138 
of  jaundice,  142 
of  knee-joint  disease,  330 
of  la  grippe,  356 
of  lentigo,  311 
of  leukaemia,  202 
of  lobar  pneumonia,  241 
of  malaria,  362 

of  malignant  endocarditis,  186 
of  malnutrition,  162 
of  marasmus,  165 
of  mastitis  in  the  new-born,  37 
of  masturbation,  305 
of  measles,  336 

of  melaena  in  the  new-born,  36 
of  membranous  laryngitis,  226 

rhinitis,  217 
of  meningocele  of  the  new-born,  39 
of  miliaria,  313 
of  mumps,  354 
of  naevus,  196 
of  nasal  polypi,  219 
of  oedema  glottidis,  231 
of  ophthalmia,  32 


INDEX. 


385 


Treatment  of  papilloma  of  larynx,  230 
of  perinephritis,  269 
of  peripheral  neuritis,  273 
of  peritonsillar  abscess,  86 
of  pernicious  anaemia,  200 
of  phimosis,  270 
of  pin-worms,  133 
of  pleurisy  with  effusion,  249 
of  polypus  recti,  140 
of  Pott's  disease,  327 
of    progressive    muscular    atrophy, 

278 
of  prolapsus  ani,  136 
of  pruritus  ani,  136 
of    pseudo-hypertrophic     muscular 

paralysis,  279 
of  pseudo-leukEemia,  204 
of  pulmonary  atelectasis,  247 

emphysema,  243 

gangrene,  246 
of  purpura,  209 
of  pyelitis,  267 
of  rachitis,  173 
of  ranula,  79 
of  renal  calculi,  268 
of  retropharyngeal  abscess,  82 
of  rotheln,  337 
of  round  worm,  132 
of  scabies,  319 
of  scarlet  fever,  341 
of  sclerema  in  the  new-born,  37 
of  scorbutus,  168 
of  seborrhoea,  312 
of  secondary  anaemia,  199 
of  sepsis  in  the  new-born,  34 
of  simple  anremia,  198 
of  sleep-disorders,  304 
of  spasmodic  laryngitis,  221 
of  spina  bifida,  39 
of  suppurative  hepatitis,  145 
of  syphilis,  367 
of  syphilitic  rhinitis,  218 
of  tapeworms,  135 
of  tetanus  in  the  new-born,  35 
of  tetany,  296 
of  thrush,  77 

of  tinea  trichophytina,  320 
of  transverse  myelitis,  276 
of  tubercular  adenitis,  310 

dactylitis,  331 

meningitis,  283 

peritonitis,  160 
of  tumors  of  kidney,  266 
of  typhoid  fever,  '■'>'>'■> 
of  ulcer  of  stomach,  96 
of  ulcerative  stomatitis,  75 

25- D.  C. 


Treatment  of  umbilical  hernia  in  the 
new-born,  37 
of  urticaria,  318 
of  vaccination,  333 
of  varicella,  334 
of  vulvo-vaginitis,  271 
of  whooping-cough,  351 
Tubercular  dactylitis,  330 
diagnosis  of,  330 
prognosis  of,  330 
symptoms  of,  330 
treatment  of,  331 
enteritis,  chronic,  118 
symptoms  of,  118 
treatment  of,  119 
Tuberculosis,  pulmonary,  acute,  252 
diagnosis  of,  253 
etiology  of,  252 
pathology  of,  252 
physical  signs  of,  253 
prognosis  of,  253 
symptoms  of,  252 
treatment  of,  253 
chronic,  254 
diagnosis  of,  255 
etiology  of,  254 
pathology  of,  254 
physical  signs  of,  255 
prognosis  of,  255 
symptoms  of,  254 
treatment  of,  255 
Typhoid  fever,  356 

complications  of,  358 
diagnosis  of,  359 
etiology  of,  356 
incubation-period  of,  357 
pathology  of,  356 
prognosis  of,  359 
symptoms  of,  357 
treatment  of,  359 

u. 

Ulcer  of  stomach,  96 

etiology  of,  96 

pathology  of,  96 

prognosis  of,  96 

symptoms  of,  96 

treatment  of,  96 
Umbilical  cord,  20 

ligation  of,  20 

pulsation  of,  20 
hernia  in  the  new-born,  37 
Umbilicus,  granuloma  of,  in  the  new- 
born, 36 

treatment  of,  37 


386 


INDEX. 


Urticaria,  318 
etiology  of,  318 
prognosis  of,  318 
symptoms  of,  318 
treatment  of,  318 

V. 

Vaccination,  332 
abnormalities  of,  333 
complications  of,  333 
method  of  performance  of,  332 
symptoms  of,  333 
time  for  performance  of,  332 
treatment  of,  333 
Varicella,  334 
complications  of,  334 
diagnosis  of,  334 
etiology  of,  334 
incubation-period  of,  334 
prognosis  of,  334 
symptoms  of,  334 
treatment  of,  334 
Vesical  calculus,  258 

diagnosis  of,  259 

etiology  of,  258 

prognosis  of,  259 

symptoms  of,  258 

treatment  of,  259 
Vulvo-vaginitis,  270 
diagnosis  of,  271 


Vulvo-vaginitis,  etiology  of,  270 
symptoms  of,  271 
treatment  of,  271 

w. 

Weaning  of  infant,  54 
Wet-nursing,  51 
Whey,  70 

Whooping-cough,  349 
complications  of,  351 
diagnosis  of,  351 
etiology  of,  349 
incubation-period  of,  349 
pathology  of,  349 
physical  signs  of,  351 
prognosis  of,  351 
symptoms  of,  349 
treatment  of,  351 
Worms,  pin-,  132 
diagnosis  of,  133 
symptoms  of,  133 
treatment  of,  133 
round,  131 
diagnosis  of,  132 
symptoms  of,  131 
treatment  of,  132 
tape,  diagnosis  of,  135 
habitat,  134 
varieties,  134 


CATALOGUE  OF  PUBLICATIONS  OF 

LEA    BROTHERS    &    COMPANY, 

~.Oii,  708  &  710  Sansom  St.,  Philadelphia. 
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United  States,  on  receipt  of  the  printed  prices. 

INDEX. 

ANATOMY.     Gray,  p.  11  ;  Treves,  30  ;  Gerrish,  11;  Brockway,  4. 

DICTIONARIES.     Dunglison,  p.  8  ;  Duane,  8  ;  National,  4. 

PHYSICS.     Draper,  p.  8  ;  Eobertson,  24  ;  Martin  &  Eockwell,  20. 

PHYSIOLOGY     Foster,  p.  10;  Chapman,  5;  Schofield,  25;   Collins 
&  Eockwell,  6.  ■  [Luff,  19  ;  Eemsen,  24. 

CHEMISTRY.      Simon,  p.  26  ;  Attfield,  3  ;  Martin  &  Eockwell,  20; 

PHARMACY.     Caspari,  p.  5.  [Bruce,  4  :  Schleif,  25. 

MATERIA   MEDICA.     Culbretb,  p.  6  ;   Maisch,  19  ;  Farquharson,  9  ; 

DISPENSATORY.     National,  p.  21. 

THERAPEUTICS.      Hare,  p.  13  ;  Fothergill,  10  ;  Whitla,  31  ;  Hayem 
&  Hare,  14  ;  Bruce,  4  ;  Schleif,  25  ;  Cushny,  6. 

PRACTICE.     Flint,  p.  9  ;  Loomis  &  Thompson,  19  ;  Malsbary,  20. 

DIAGNOSIS.     Musser,  p.  21 ;  Hare,  12;  Simon,  25;  Herrick,  15;  Hutchi- 
son &  Rainey,  16  ;  Collins,  6. 

CLIMATOLOGY.     Solly,  p.  26  ;  Hayem  &  Hare,  14. 

NERVOUS  DISEASES.     Dercum,  p.  7  ;    Gray,  11  ;  Potts,  23. 

MENTAL  DISEASES.     Clouston,  p.  5  ;  Savage,  24 ;  Folsom,  10. 

BACTERIOLOGY.       Abbott,  p.  2 ;    Vaughan  &  Novy,  30;    Senn's 
(Surgical),  25.      Park,  22  ;  Coates,  6.  [Vale,  21. 

HISTOLOGY.     Klein,  p.  17  ;   Schafer's,  25  ;    Dunham,  8  ;  Nichols  & 

PATHOLOGY.    Green,  p.  12;  Gibbes,  10;  Coats,  6;  Nichols  &  Vale,  21 

SURGERY.     Park,  p.  22;  Dennis,  7;  Eoberts,  24;  Ashhurst,  3;  Treves,  29; 
Cheyne  &  Burghard,  5  ;  Gallaudet,  10. 

SURGERY— OPERATIVE.     Stimson,  p.  27  ;  Smith,  26  ;  Treves,  29. 

SURGERY— ORTHOPEDIC.     Young,  p.  31  ;  Gibney,  10. 

SURGERY— MINOR.     Wharton,  p.  30.  [Ballenger  & 

FRACTURES  and  DISLOCATIONS.   Stimson,  p.  27.  [Wippern,  3. 

OPHTHALMOLOGY.    Norris  &  Oliver,  p.  21;  Nettleship,  21 ;  Juler,17; 

OTOLOGY.  Politzer,  p.  23;  Burnett,  5;  Field,  9;  Bacon,  4. 

LARYNGOLOGY  and  RHINOLOGY.  Coakley,  p.  6  ; 

DENTISTRY.     Essig  (Prosthetic),  p.  9  ;  Kirk  (Operative),  17  ;   Ameri- 
can System,  2  ;  Coleman,  6;  Burchard   4. 

URINARY  DISEASES.     Eoberts,  p.  24  ;  Black,  4  ;  Morris,  20. 

VENEREAL    DISEASES.      Taylor,  p.  28  ;    Hayden,  14  ;    Cornil,  6  ; 
Likes,  19. 

SEXUAL   DISORDERS.     Fuller,  p.  10  ;  Taylor,  29. 

DERMATOLOGY.      Hyde,  p.  16  ;  Jackson,  16  ;  Pye-Smith,  24  ;  Mor- 
ris, 20  ;  Jamieson,  16  ;  Hardaway,  12  ;  Grindon,  12. 

GYNECOLOGY.      American  System,  p.  3  ;    Thomas    &  Mnnd6,  29 
Emmet,  9  ;  Davenport,  7  ;  May,  20  ;  Dudley,  8  ;  Crockett,  6. 

OBSTETRICS.     American  System,  p.  3  ;    Davis,  7  ;   Parvin,  22  ;   Play- 
fair.  23  ;  King,  17  ;  Jewett,  17  ;  Evans,  9. 

PEDIATRICS.    Smith,  p.  26  ;  Thomson,  29  ;  Williams,  31  ;  Tuttle,  30. 

HYGIENE.     Egbert,  p.  9  ;  Richardson,  24  ;  Coates,  6. 

MEDICAL  JURISPRUDENCE.     Taylor,  p.  28. 

QUIZ   SERIES,  POCKET  TEXT-BOOKS  and  MANUALS. 
Pp.  18,  25  and  27. 
9.1.9 


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detail,  make  his  experiments    sue- 1 


AMERICAN  SYSTEM  OF  PRACTICAL  MEDICINE.  A  SYS- 
TEM OF  PRACTICAL  MEDICINE.  In  contributions  by  Various 
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MEDICINE.    Edited  by  Roswell  Paek,  M.D.     See  page  22. 

ASHHURST  (JOHN,  JR.).  THE  PRINCIPLES  AND  PRACTICE 
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is  a  valuable  text-book  on  a  subject 
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In  the  treatment  of  the  subject 
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is  logical  and  sequential.   The  work 


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680  pages,  with  288  illustrations.     Cloth,  $4.50. 

The  author's  duties  as  Professor  '  student  who  cannot  understand  must 
of  Theory  and  Practice  of  Pharmacy  be  dull  indeed.  The  book  is  full  of 
in  the  Maryland  College  of  Phar-  j  new,  clean,  sharp  illustrations, which 
macy,  and  his  contact  with  students  I  tell  the  story  frequently  at  a  glance, 
made  him  aware  of  their  exact  !  The  index  is  full  and  accurate. — 
wants  in  the  matter  of  a  manual,  j  National  Druggist. 
His    work    is   admirable,   and  the  I 

CHAPMAN  (HENRY  C).  A  TREATISE  ON  HUMAN  PHYSI- 
OLOGY. New  (2d)  edition.  In  one  octavo  volume  of  921  pages, 
with  595  illustrations.     Just  ready.     Cloth,  $4.25 ;  leather,  $5.25,  net. 


In  every  respect  the  work  fulfils 
its  promise,  whether  as  a  complete 
treatise  for  the  student  or  as  an  ad- 


mirable work  of  reference  for  the 
physician. — North  Carolina  Medical 
Journal. 


CHARLES  (T.  CRANSTOUN).  THE  ELEMENTS  OF  PHYSIO- 
LOGICAL AND  PATHOLOGICAL  CHEMISTRY.  Octavo,  451 
pages,  with  38  engravings  and  1  colored  plate.     Cloth,  $3.50. 

CHEYNE  (W.  WATSON).  THE  TREATMENT  OF  WOUNDS, 
ULCERS  AND  ABSCESSES.  In  one  12mo.  volume  of  207  pages. 
Cloth,  $1.25. 

One    will    be    surprised     at    the  need  at  any  moment.     The  sections 

amount  of  practical  and  useful  in-  devoted  to  ulcers  and  abscesses  are 

formation  it  contains;  information  indispensable   to  any  physician. — 

that  the    practitioner  is    likely  to  The  Charlotte  Medical  Journal. 

CHEYNE  (W.  W.)  AND  BURGHARD  (F.  F.)  SURGICAL 
TREATMENT.  In  six  octavo  volumes,  illustrated.  Volume  1,  299 
pages  and  66  engravings,  just  ready.     Cloth,  $3.00  net. 

CLARKE  (W.  B.)  AND  LOCKWOOD  (C.  B.).  THE  DISSECTOR'S 
MANUAL.  In  one  12mo.  volume  of  396  pages,  with  49  engravings. 
Cloth,  $1.50.     See  Students'  Series  of  3Ianuals,  page  27. 

CLELAND  (JOHN).  A  DIRECTORY  FOR  THE  DISSECTION  OF 
THE  HUMAN  BODY.     In  one  12mo.vol.  of  178  pages.    Cloth,  $1.25. 

CLINICAL  MANUALS.     See  Series  of  Clinical  Mamials,  page  25. 

CLOUSTON  (THOMAS  S.).    CLINICAL  LECTURES  ON  MENTAL 

IHSEASES.     New  (5th)  edition.     In  one  octavo  volume  of  750  pages, 
with  111  colored  plates.     Cloth,  $4.25,   int.     Just  rrm/y. 
^?*-Folso.m's  Abstract  of  Laws  of  U.  S.  on  Custody  of  Insane,  octavo, 
$1.50,  is  sold  in   conjunction  with  C/oustou  on  Mental  Diseases  for 
$5.00,  net,  for  the  two  works. 


6      Lea  Brothers  &  Co.,  Philadelphia  and  New*  Yoke. 

CLOWES  (FRANK).  AN  ELEMENTAEY  TREATISE  ON  PRACTI- 
CAL CHEMISTRY  AND  QUALITATIVE  INORGANIC  ANALY- 
SIS. From  the  fourth  English  edition.  In  one  handsome  12mo. 
volume  of  387  pages,  with  55  engravings.     Cloth,  $2.50. 

COAKLEY  (CORNELIUS  G.).  THE  DIAGNOSIS  AND  TREAT- 
MENT OF  DISEASES  OF  THE  NOSE,  THROAT,  NASO- 
PHARYNX AND  TRACHEA.  In  one  12mo.  volume  of  about  400 
pages,  fully  illustrated.    Preparing, 

COATES  (W.  E.,  JR.).  A  POCKET  TEXT-BOOK  OF  BACTE- 
RIOLOGY AND  HYGIENE.  In  one  handsome  12mo.  volume  of 
about  350  pages,  with  many  illustrations.  Shortly.  Cloth,  $1.50,  net. 
Lea's  Series  of  Pocket  Text-books,  edited  by  Bern  B.  Gallaudet, 
M.  D.     See  page  18. 

COATS  (JOSEPH).  A  TREATISE  ON  PATHOLOGY.  In  one  vol. 
of  829  pages,  with  339  engravings.     Cloth,  $5.50 ;  leather,  $6.50. 

COLEMAN  (ALFRED).  A  MANUAL  OF  DENTAL  SURGERY 
AND  PATHOLOGY.  With  Notes  and  Additions  to  adapt  it  to  Amer- 
ican Practice.  By  Thos.  C.  Stellwagen,  M.A.,  M.D.,  D.D.S.  In  one 
handsome  octavo  vol.  of  412  pages,  with  331  engravings.    Cloth,  $3.25. 

COLLINS  (C.  P.).  A  POCKET  TEXT-BOOK  OF  MEDICAL 
DIAGNOSIS.  In  one  handsome  12mo.  volume  of  about  350  pages, 
with  many  illustrations.  Shortly.  Cloth,$1.50,  net.  Lea' s  Series  of  Pocket 
Text-books,  edited  by  Bern  B.  Gallaudet,  M.  D.     See  page  18. 

COLLINS  (H.  D.)  AND  ROCKWELL  (W.  H.).  A  POCKET 
TEXT-BOOK  OF  PHYSIOLOGY.  In  one  handsome  12mo.  volume 
of  about  300  pages,  with  many  illustrations.  Cloth,  $1.50,  net.  In  press. 
Lea's  Series  of  Pocket  Text-books,  edited  by  Bern  B.  Gallaudet, 
M.  D.    See  page  18. 

CONDLE  (D.  FRANCIS).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES OF  CHILDREN.  Sixth  edition,  revised  and  enlarged.  In 
one  large  8vo.  volume  of  719  pages.     Cloth,  $5.25 ;  leather,  $6.25. 

CORNIL  (V.).  SYPHILIS:  ITS  MORBID  ANATOMY,  DIAGNO- 
SIS AND  TREATMENT.  Translated,  with  Notes  and  Additions,  by 
J.  Henry  C.  Simes,  M.D.  and  J.  William  White,  M.  D.  In  one 
8vo.  volume  of  461  pages,  with  84  illustrations.     Cloth,  $3.75. 

CROCKETT  (M.  A.).      A  POCKET  TEXT-BOOK   OF  DISEASES 

OF  WOMEN.  In  one  handsome  12mo.  volume  of  about  350  pages, 
with  many  illustrations.  Cloth,$1.50,  net.  Shortly.  Lea's  Series  of  Pocket 
Text-books,  edited  by  Bern  B.  Gallaudet,  M.  D.     See  page  18. 

CROOK  (JAMES  K.)  ON  MINERAL  WATERS  OF  THE 
UNITED  STATES.    Octavo,  575  pages.   Just  ready.   Cloth,  $3.50,  net. 

CULBRETH  (DAVID  M.  R.).  MATERIA  MEDICA  AND  PHAR- 
MACOLOGY. In  one  handsome  octavo  volume  of  812  pages,  with 
445  illustrations.     Cloth,  $4.75. 


A  thorough,  authoritative  and 
systematic  exposition  of  its  most 
important  domain.  —  The  Canada 
Lancet. 

This  work  ought  to  be  at  once 


adopted  as  the  text-book  in  all  col- 
leges of  pharmacy  and  medicine. 
It  is  one  of  the  most  valuable  works 
that  have  been  issued. — The  Ohio 
Medical  Journal. 


CUSHNY    (ARTHUR  R.).    TEXT-BOOK  OF  PHARMACOLOGY. 

Handsome  8vo.,  728  pages,  with  47  illus.  Just  ready.  Cloth,  $3.75,  net. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.       7 

DAI/TON  (JOHN  C).   A  TREATISE  ON  HUMAN  PHYSIOLOGY. 

Seventh  edition.     Octavo,   722  pages,  with   252  engravings.     Cloth, 
$5 ;  leather,  $6. 


DOCTRINES  OF  THE  CIRCULATION  OF  THE  BLOOD.  In 


one  handsome  12mo.  volume  of  293  pages.     Cloth, 

DAVENPORT  (P.  H.).      DISEASES  OF  WOMEN.      A  Manual  of 

Gynecology.  For  the  use  of  Students  and  Practitioners.  New 
(3d)  edition.  In  one  handsome  12mo.  volume  of  387  pages,  with  150 
illustrations.     Cloth,  $1.75,  net.    Just  ready. 

DAVIS  (EDWARD  P.).  A  TREATISE  ON  OBSTETRICS.  FOR 
STUDENTS  AND  PRACTITIONERS.  In  one  very  handsome 
octavo  volume  of  546  pages,  with  217  engravings  and  30  full-page 
plates  in  colors  and  monochrome.    Cloth,  $5;  leather,  $6. 


This  work  must  become  the  prac- 
titioner's text-book  as  well  as  the 
student's.  It  is  up  to  date  in  every 
respect. —  Va.  Med.  Semi-Monthly. 

A  Avork  unequalled  in  excellence. 
—  The  Chicago  Clinical  Review. 

Decidedly  one  of  the  best    text- 


books on  the  subject.  It  is  exception- 
ally useful  from  every  standpoint. — 
Nashville  Jour,  of  Med.  and  Surgery. 
From  a  practical  standpoint  the 
work  is  all  that  could  be  desired.  A 
thoroughly  scientific  and  brilliant 
treatise  on  obstetrics.  —Med.  News. 


DAVIS  (F.  H.).    LECTURES  ON  CLINICAL  MEDICINE.    Second 
edition.     In  one  12mo.  volume  of  287  pages.     Cloth,  $1.75. 

DE  LA  BECHE'S  GEOLOGICAL  OBSERVER.     In  one  large  octavo 
volume  of  700  pages,  with  300  engravings.     Cloth,  $4. 

DENNIS  (FREDERIC  S.)  AND  BDLLJJVGS  (JOHN  S.).  A  SYS- 
TEM OF  SURGERY.  In  contributions  by  American  Authors. 
Complete  work  in  four  very  handsome  octavo  volumes,  containing 
3652  pages,  with  1585  engravings  and  45  full-page  plates  in  colors 
and  monochrome.  Per  volume,  cloth,  $6.00;  leather,  $7.00;  half 
Morocco,  gilt  back  and  top,  $8.50.  For  sale  by  subscription  only. 
Full  prospectus  free  on  application  to  the  publishers. 
It  is  worthy  of  the  position  which 

surgery   has  attained  in  the  great 

Republic   whence    it  comes.  —  The 

London  Lancet. 


It  may  be  fairly  said  to  represent 
the    most     advanced    condition    of 


American  surgery  and  is  thoroughly 
practical. — Annals  of  Surgery. 

No  work  in  English  can  be  con- 
sidered as  the  rival  of  this. —  The 
American  Journal  of  the  Medical 
Sciences. 


DERCUM  (FRANCIS  X.,  EDITOR).  A  TEXT-BOOK  ON 
NERVOUS  DISEASES.  By  American  Authors.  In  one  handsome 
octavo  volume  of  1054  pages,  with  341  engravings  and  7  colored 
plates.     Cloth,  $6.00;  leather,  $7.00.    Net. 

Representing  the  actual  status  of       The  work  is  representative  of  the 
our  knowledge  of  its  subjects,  and  |  best  methods  of  teaching,  as  devel 


the  latest  and  most  fully  up-to-date 
of  any  of  its  class. — Jour,  of  Amer- 
ican Med.  Association. 

The  most  thoroughly  up-to-date 
tnalise  that  we  have  on  this  subject. 
— American.  Journal  of  Insanity. 


oped  in  the  leading  medical  colleges 
of  this  country.—  Alienist  and  Neu- 
rologist. 

The  best  text-book   in  any  lan- 
guage.— The  Medical  Fortnightly. 


DE  SCHWEnSTITZ  (GEORGE  E.).  THE  TOXIC  AMBLYOPIAS. 
Their  Classification,  History,  Symptoms,  Pathology  and  Treatment. 
Very  handsome  octavo,  240  pages,  46  engravings,  and  9  full-page 
plates  in  colors.     Limited  edition,  de  luxe  binding,  $4.    Net. 


8      Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

DRAPER  (JOHN  C).  MEDICAL  PHYSICS.  A  Text-book  for  Stu- 
dents arid  Practitioners  of  Medicine.  In  one  handsome  octavo  volume 
of  734  pages,  with  376  engravings.     Cloth,  $4. 

DRUITT  (ROBERT).  THE  PRINCIPLES  AND  PBACTICE  OF 
MODERN  SURGERY.  A  new  American,  from  the  twelfth  London 
edition,  edited  by  Stanley  Boyd,  F.  R.  C.  S.  In  one  large  octavo 
volume  of  965  pages,  with  373  engravings.     Cloth,  $4 ;  leather,  $5. 

DUANE  (ALEXANDER).  THE  STUDENT'S  DICTIONARY  OF 
MEDICINE  AND  THE  ALLIED  SCIENCES.  New  edition.  Com- 
prising the  Pronunciation,  Derivation  and  Full  Explanation  of  Medi- 
cal Terms,  with  much  Collateral  Descriptive  Matter.  Numerous  Tables, 
etc.  Square  octavo  of  658  pages.  Cloth,  $3.00 ;  half  leather,  $3.25 ; 
full  sheep,  $3.75.    Thumb-letter  Index,  50  cents  extra. 


convenience    and    thoroughness.  — 
Medical  Record. 

The  best  student's  dictionary. — 
Canada  Lancet. 


Far  superior  to  any  dictionary  for 
the  medical  student  that  we  know  of. 
—  Western  Med.  and  Surg.  Reporter. 
The  book  is  brought  accurately  to 
date.     It  is  a  model  of  conciseness, 
DUDLEY    (E.    C).      THE    PRINCIPLES    AND    PRACTICE    OF 
GYNECOLOGY.     Handsome  octavo  of  652  pages,  with  422  illustra- 
tions in  black  and  colors.     Cloth,  $5.00,  net;  leather, $6.00,  net.    Just 
ready. 


tice  of  modern  gynecology. — Inter- 
national Medical  Magazine. 


The  book   can  be   safely    recom- 
mended as  a  complete  and  reliable 
exjtosition  of  the  principles  and  prac- 
DUNCAN  (J.  MATTHEWS).     CLINICAL   LECTURES    ON    THE 
DISEASES  OF  WOMEN.   Delivered  in  St.  Bartholomew's  Hospital. 
In  one  octavo  volume  of  175  pages.     Cloth,  $1.50. 
DUNGL.ISON  (ROBLEY).   A  DICTIONARY  OF  MEDICAL  SCI- 
ENCE.    Containing  a  full  explanation  of  the  various  subjects  and 
terms  of  Anatomy,  Physiology,  Medical  Chemistry,  Pharmacy,  Phar- 
macology, Therapeutics,  Medicine,  Hygiene,  Dietetics,  Pathology,  Sur- 
gery, Ophthalmology,  Otology,  Laryngology,  Dermatology,  Gynecol- 
ogy, Obstetrics,  Pediatrics,  Medical  Jurisprudence,  Dentistry,  etc.,  etc. 
By  Robley  Dtjnglison,  M.  D.,  LL.  D.,  late   Professor  of  Institutes 
of  Medicine  in  the  Jefferson  Medical  College  of  Philadelphia.  Edited 
by  Richard  J.  Dunglison,  A.  M.,  M.  D.  Twenty-first  edition,  thor- 
oughly revised  and  greatly  enlarged  and  improved,  with  the  Pronuncia- 
tion, Accentuation  and  Derivation  of  the  Terms.     With  Appendix. 
In  one  magnificent  imperial  octavo  volume  of  1225  pages.     Cloth,  $7  ; 
leather,  $8.    Thumb-letter  Index  for  quick  use,  75  cents  extra. 
The  most  satisfactoiy  and  authori- ,  scarcely  be  measured. — Med.  Record. 
tative  guide  to  the  derivation,  defini-  ;      Pronunciation  is  indicated  by  the 
tion  and  pronunciation   of  medical  |  phonetic  system.  The  definitions  are 


unusually  clear  and  concise.  The 
book  is  wholly  satisfactory. —  Uni- 
versity Medical  Magazine. 


terms. — The  Charlotte  Med.  Journal. 
Covering  the  entire  field  of  medi- 
cine,   surgery    and    the     collateral 

sciences,  its  range  of  usefulness  can 

DUNHAM  (EDWARD    K.).       MORBID    AND     NORMAL     HIS- 
TOLOGY.    Octavo,  450  pages,with  363  illustrations.  Cloth,  $3.25,  net. 
Just  ready. 
The  best  one-volume  text  or  refer- 1  of  published  in  America. —  Virginia 

ence  book  on  histology  that  we  know  I  Medical  Semi-Monthly. 

EDES  (ROBERT  T.).  TEXT-BOOK  OF  THERAPEUTICS  AND 
MATERIA  MEDICA.  In  one  8vo.  volume  of  544  pages.  Cloth,  $3.50 ; 
leather,  $4.50. 

EDIS  (ARTHUR  W.).  DISEASES  OF  WOMEN.  A  Manual  for 
Students  and  Practitioners.  In  one  handsome  8vo.  volume  of  576  pages, 
with  148  engravings.    Cloth,  $3 ;  leather,  $4. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York:.      9 

EGBERT  (SENECA).    A   MANUAL   OF  HYGIENE  AND  SANI- 
TATION.    In  one  12mo.  volume  of  359  pages,  with  63  illustrations. 
Just  ready.     Cloth,  Net,  $2.25. 
It  is  written  in  plain  language,    ligence.     The  writer  has  adapted  it 

and,  while  primarily  designed  for    to    American    conditions,   and  _  his 

physicians,  it  can  be  studied  with    suggestions  are,  above  all,  practical. 

profit  by  any  one  of  ordinary  intel-    — The  New  York  Medical  Journal. 

ELLIS  (GEORGE  VTNER).  DEMONSTRATIONS  IN  ANATOMY. 

Eighth  edition.     Octavo,   716  pages,   with   249  engravings.     Cloth, 
$4.25 ;  leather,  $5.25. 
EMMET    (THOMAS    ADDIS).     THE  PRINCIPLES  AND  PRAC- 
TICE OF  GYNAECOLOGY.    Third  edition.   Octavo,  880  pages,  with 
150  original  engravings.     Cloth,  $5 ;  leather,  $6. 

ERICHSEN  (JOHN  E.).  THE  SCIENCE  AND  ART  OF  SUR- 
GERY. Eighth  edition.  In  two  large  octavo  volumes  containing 
2316  pages,  with  984  engravings.     Cloth,  $9  ;  leather,  $11. 

ESSIG  (CHARLES  J.).   PROSTHETIC  DENTISTRY.  See  American 

Text-Books  of  Dentistry,  page  2. 

EVANS  (DAVID  J.).  A  POCKET  TEXT-BOOK  OF  OBSTETRICS. 
In  one  handsome  12mo.  volume  of  about  300  pages,  with  many  illustra- 
tions. Cloth,  $1.50,  net.  Shortly.  Lea's  Series  of  Pocket  Text-books, 
edited  by  Bern  B.  Gallaitdet,  M.  D.    See  page  18. 

PARQUHARSON  (ROBERT).  A  GUIDE  TO  THERAPEUTICS. 
Fourth  American  from  fourth  English  edition,  revised  by  Frank 
Woodbury,  M.  D.     In  one  12mo.  volume  of  581  pages.    Cloth,  $2.50. 

FEELD  (GEORGE  P.).  A  MANUAL  OF  DISEASES  OF  THE 
EAR.  Fourth  edition.  In  one  octavo  volume  of  391  pages,  with  73 
engravings  and  21  colored  plates.      Cloth,  $3.75. 


It  is  just  such  a  work  as  is  needed 
by  every  general  practitioner.  — 
American  Practitioner  and  News. 


To  those    who    desire    a  concise 
work   on  diseases  of  the  ear,  clear 
and    practical,    this  manual    com- 
mends itself  in  the  highest  degree. 
FLINT  (AUSTEV).    A   TREATISE   ON   THE  PRINCIPLES  AND 
PRACTICE    OF   MEDICINE.     Seventh  edition,  thoroughly  revised 
by  Frederick  P.  Henry,  M.D.    In  one  large  8vo.  volume  of  1143 
pages,  with  engravings.     Cloth,  $5.00 ;  leather,  $6.00. 
The  work  has  well  earned  its  lead-  I  medicine  in  the  medical  schools. — 
ing  place  in   medical  literature. —    Northwestern  Lancet. 
Medical  Record.  The  best  of  American  text-books 

_,,,,.  .  ,      .  t    on  Practice. — Amer. Medico-Surgical 

The  leading  text-book  on  general    j^unenn 

A   MANUAL   OF   AUSCULTATION  AND  PERCUSSION ;  of 

the  Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of 
Thoracic  Aneurism.  Fifth  edition,  revised  by  James  C.  Wilson,  M.D. 
In  one  handsome  12mo.  volume  of  274  pages,  with  12  engravings. 

A    PRACTICAL   TREATISE    ON    THE    DIAGNOSIS    AND 

TREATMENT  OF  DISEASES  OF  THE  HEART.  Second  edition 
enlarged.     In  one  octavo  volume  of  550  pages.     Cloth,  $4. 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLO- 
RATION OF  THE  CHEST,  AND  THE  DIAGNOSIS  OF  DIS- 
EASES AFFECTING  THE  RESPIRATORY  ORGANS.  Second 
and  revised  edition.     In  one  octavo  volume  of  591  pages.   Cloth,  $4.50. 

MEDICAL  F.SSA  VS.    In  one  12mo.  vol.  of  210  pages.  Cloth, $1.38. 

ON  PHTHISIS:  ITS  MORBID  ANATOMY   ETIOLOGY,  ETC. 

A  Series  of  Clinical  Lectures.  In  one  8vo.  volume  of  442  pages. 
Cloth,  $3.50. 


10     Lea  Bbothers  &  Co.,  Philadelphia  and  New  Yoek. 

FOLSOM  (C.  P.).  AN  ABSTRACT  OF  STATUTES  OF  U.  S. 
ON  CUSTODY  OF  THE  INSANE.  In  one  8vo.  vol.  of  108  pages. 
Cloth,  $1.50.  With  Clouston  on  Mevtal  Diseases  (new  edition,  see 
page  6)  $5.00,  net,  for  the  two  works. 

FORMULARY,  POCKET,  see  page  32. 

FOSTER  (MICHAEL).    A  TEXT-BOOK  OF  PHYSIOLOGY.    New 

(6th)  and  revised  American  from  the  sixth  English  edition.     In  one 

large  octavo  volume  of  923  pages,  with  257  illustrations.     Cloth,  $4.50 ; 

leather,  $5.50. 

Unquestionably  the  best  book  that  I      This    single    volume  contains  all 

can  be  placed  in  the  student's  hands,  i  that  will  be  necessary  in  a  college 

and  as  a  work  of  reference  for  the  I  course,  and  all  that  the  physician 

busy  physician  it  can  scarcely  be  ,  will  need  as  well. — Dominion  Med. 

excelled. —  The  Phi  la.  Polyclinic.        j  Monthly. 

FOTHERGELL  (J.  MILNER).  THE  PRACTITIONER'S  HAND- 
BOOK OF  TREATMENT.  Third  edition.  In  one  handsome  octavo 
volume  of  664  pages.     Cloth,  $3.75 ;  leather,  $4.75. 


To  have  a  description  of  the 
normal  physiological  processes  of  an 
organ  and  of  the  methods  of  treat- 
ment of  its  morbid  conditions 
brought  together  in  a  single  chapter, 
and  the  relations    between  the  two 


clearly  stated,  cannot  fail  to  prove 
a  great  convenience  to  many  thought- 
ful but  busy  physicians.  The  jDrac- 
tical  value  of  the  volume  is  greatly 
increased  by  the  introduction  of  many 
prescriptions — New  York  Med.  Jour. 

POWNES  (GEORGE).  A  MANUAL  OF  ELEMENTARY  CHEM- 
ISTRY (INORGANIC  AND  ORGANIC).  Twelfth  edition.  Em- 
bodying Watts'  Physical  and  Inorganic  Chemistry.  In  one  royal 
12mo.  volume  of  1061  pages,  with  168  engravings,  and  1  colored 
plate.     Cloth,  $2.75;  leather,  $3.25. 

PRANKLAND  (E.)  AND  JAPP  (F.R.).  INORGANIC  CHEMISTRY. 
In  one  handsome  octavo  volume  of  677  pages,  with  51  engravings  and 
2  plates.     Cloth,  $3.75 ;  leather,  $4.75. 

FULLER  (EUGENE).  DISORDERS  OF  THE  SEXUAL  OR- 
GANS IN  THE  MALE.  In  one  very  handsome  octavo  volume  of 
238  pages,  with   25  engravings  and  8  full-page  plates.      Cloth,  $2. 


It  is  an  interesting  work,  and  one 
which,  in  view  of  the  large  and 
profitable  amount  of  work  done  in 
this  field  of  late  years,  is  timely  and 
well  needed. — Medical  Fortnightly. 

The  book  is  valuable  and  instruc- 


tive and  brings  views  of  sound 
pathology  and  rational  treatment  to 
many  cases  of  sexual  disturbance 
whose  treatment  has  been  too  often 
fruitless  for  good.  — ■  Annals  of 
Surgery. 


FULLER  (HENRY).  ON  DISEASES  OF  THE  LUNGS  AND  AIR 
PASSAGES.  Their  Pathology,  Physical  Diagnosis,  Symptoms  and 
Treatment.  From  second  English  edition.  In  one  8vo.  volume  of  475 
pages.     Cloth,  $3.50. 

GALLAUDET  (BERN  B.).  A  POCKET  TEXT-BOOK  ON  SUR- 
GERY. In  one  handsome  12mo.  volume  of  about  400  pages,  with  many 
illustrations.  Cloth,  $1.50,  net.  Shortly.  Lea's  Series  of  Pocket  Text- 
booh,  edited  by  Bern  B.  Gallaudet,  M.  D.     See  page  18. 

GANT  (FREDERICK  JAMES).  THE  STUDENT'S  SURGERY.  A 
Multum  in  Parvo.  In  one  square  octavo  volume  of  845  pages,  with 
159  engravings.     Cloth,  $3.75. 

GD3BES  (HENEAGE).  PRACTICAL  PATHOLOGY  AND  MORBID 
HISTOLOGY.   Octavo,  314  pages,  with  60  illustrations.    Cloth,  $2.75. 

GD3NEY  (V.  P.).  ORTHOPEDIC  SURGERY.  For  the  use  of  Practi- 
tioners and  Students.     In  one  8vo.  vol.  profusely  illus.    Preparing. 


Lea  Bbothebs  &  Co.,  Philadelphia  and  New  Yoek.     11 


GERRISH  (FREDERIC  H.).  A  TEXT-BOOK  OF  ANATOMY. 
By  American  Authors.  Edited  by  Frederic  H.  Gerrish,  M.  D.  In  one 
imp.  octavo  volume  of  915  pages,  with  950  illustrations  in  black  and 
colors.  Just  ready.  Clth,  $6.50;  flexible  waterproof,  $7;  leath.,$7.50,  net. 

In  this,  the  first  representative  treatise  on  Anatomy  produced  in  America, 
no  effort  or  expense  has  been  spared  to  unite  an  authoritative  text  with  the 
most  successful  anatomical  pictures  which  have  yet  appeared  in  the  world. 

The  editor  has  secured  the  co-operation  of  the  professors  of  anatomy  in 
leading  medical  colleges,  and  with  them  has  prepared  a  text  conspicuous 
for  its  simplicity,  unity  and  judicious  selection  of  such  anatomical  facts  as 
bear  on  physiology,  surgery  and  internal  medicine  in  the  most  compre- 
hensive sense  of  those  terms.  The  authors  have  endeavored  to  make  a 
book  which  shall  stand  iu  the  place  of  a  living  teacher  to  the  student,  and 
which  shall  be  of  actual  service  to  the  practitioner  in  his  clinical  work, 
emphasizing  the  most  important  subjects,  clarifying  obscurities,  helping 
most  in  the  parts  most  difficult  to  learn,  and  illustrating  everything  by  all 
available  methods. 

GOULD  (A.  PEARCE).  SURGICAL  DIAGNOSIS.  In  one  12mo. 
vol.  of  589  pages.     Cloth,  $2.  See  Student's  Series  of  Manuals,  p.  27. 

GRAY  (HENRY).     ANATOMY,  DESCRIPTIVE  AND  SURGICAL. 

New  and  thoroughly  revised  American  edition,  much  enlarged  in  text, 
and  in  engravings  in  black  and  colors.  In  one  imperial  octavo  volume 
of  1239  pages,  with  772  large  and  elaborate  engravings  on  wood.  Price 
of  edition  with  illustrations  in  colors  :  cloth,  $7  ;  leather,  $8.  Price 
of  edition  with  illustrations  in  black :  cloth,  $6 ;  leather,  $7. 


This  is  the  best  single  volume 
upon  Anatomy  in  the  English 
language. —  University  Medical  Mag- 
azine. 

Gray's  Anatomy  affords  the  student 
more  satisfaction  than  any  other 
treatise  with  which  we  are  familiar. 
— Buffalo  Med.  Journal. 

The  most  largely  used  anatomical 
text-book  published  in  the  English 
language. — Annals  of  Surgery. 

Particular  stress  is  laid  upon  the 
practical  side  of  anatomical  teach- 


ing, and  especially  the  Surgical 
Anatomy. —  Chicago  Med.  Recorder. 

Holds  first  place  in  the  esteem  of 
both  teachers  and  students. —  The 
Brooklyn  Medical  Journal. 

The  foremost  of  all  medical  text- 
books.— Medical  Fortnightly. 

Gray's  Anatomy  should  be  the 
first  work  which  a  medical  student 
should  purchase,  nor  should  he  be 
without  a  copy  throughout  his  pro- 
fessional career. — Pittsburg  Medical 
Review. 


GRAY  (LANDOX  CARTER).  A  TREATISE  ON  NERVOUS  AND 
MENTAL  DISEASES.  For  Students  and  Practitioners  of  Medicine. 
New  (2d)  edition.  In  one  handsome  octavo  volume  of  728  pages,  with 
172  engravings  and  3  colored  plates.     Cloth,  $4.75;   leather,  $5.75. 


An  up-to-date  text-book  upon 
uervous  and  mental  diseases  com- 
bined. A  well-written,  terse,  ex- 
plicit, and  authoritative  volume 
treating  of  both  subjects  is  a  step  in 
the  direction  of  popular  demand. — 
The  Chicago  clinical  Review. 

"The  word  treatment,"  Says  the 
author,  "has  been  construed  in  the 
broadest  sense  to  include  not  only 
medicinal  and  non-medicinal  agents, 
but  also  those  hygienic  and  dietetic 


measures  which  are  often  the  physi- 
cian's best  reliance."—  The  Journal 
of  the  American  Medical  Association. 
The  descriptions  of  the  various 
diseases  are  accurate  and  the  symp- 
toms and  differential  diagnosis  are 
set  before  the  student  in  such,  a  way 
as  to  be  readily  comprehended.  The 
author's  loir.'  experience  renders  his 
views  on  therapeutics  of  great  value. 
—  The  Journal  of  Nervous  and  Men- 
tal Disease. 


12      Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 


GREEN  (T.  HENRY).  AN  INTRODUCTION  TO  PATHOLOGY 
AND  MORBID  ANATOMY.  New  (8th)  American  from  the  eighth 
London  edition.  In  one  handsome  octavo  volume  of  582  pages,  with 
216  engravings  and  a  colored  plate.     Cloth,  $2.50,  net.    Just  ready. 


A  work  that  is  the  text-book  of 
probably  four-fifths  of  all  the  stu- 
dents of  pathology  in  the  United 
States  and  Great  Britain  stands  in 
no  need  of  commendation.  The  work 
precisely  meets  the  needs  and  wishes 
of  the  general  practitioner.— The 
American  Practitioner  and  News. 

Green's  Pathology  is  the  text-book 


of  the  day — as  much  so  almost  as 
Gray's  Anatomy.  It  is  fully  up-to- 
date  in  the  record  of  fact,  and  so  pro- 
fusely illustrated  as  to  give  to  each 
detail  of  text  sufficient  explanation. 
The  work  is  an  essential  to  the  prac- 
titioner— whether  as  surgeon  or  phys- 
ician. It  is  the  best  of  up-to  date 
text-books.—  VirginiaMed.  Monthly. 


GREENE  (WILLIAM  H.).  A  MANUAL  OF  MEDICAL  CHEM- 
ISTRY. For  the  Use  of  Students.  Based  upon  Bowman's  Medical 
Chemistry.    In  one  12mo.  vol.  of  310  pages,  with  74  illus.    Cloth,  $1.75. 

GROSS  (SAMUEL  D.).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES, INJURIES  AND  MALFORMATIONS  OF  THE  URINARY 
BLADDER,  THE  PROSTATE  GLAND  AND  THE  URETHRA. 
Third  edition.    Octavo,  574  pages,  with  170  illustrations    Cloth,  $4.50. 

GRINDON  (JOSEPH).  A  POCKET  TEXT-BOOK  OF  SKIN 
DISEASES.  In  one  handsome  12mo.  volume  of  350  pages,  with 
many  illustrations.  Shortly.  Cloth,  $1.50,  net.  Lea's  Series  of  Pocket 
Text-books,  edited  by  Bern  B.  Gallatjdet,  M.  D.     See  page  18. 

HABERSHON  (S.  O.).  ON  THE  DISEASES  OF  THE  ABDOMEN 
Second  American  from  the  third  English  edition.  In  one  octavo  vol- 
ume of  554  pages,  with  11  engravings.     Cloth,  $3.50. 

HALL  (WINFIELD  S.)  TEXT-BOOK  OF  PHYSIOLOGY.  Octavo 
about  500  pages,  richly  illustrated.    In  press. 

HAMILTON  (ALLAN  MCLANE).  NERVOUS  DISEASES,  THEIR 
DESCRIPTION  AND  TREATMENT.  Second  and  revised  edition. 
In  one  octavo  volume  of  598  pages,  with  72  engravings.     Cloth,  $4. 


HARD  AW  AY  (W.  A.).  MANUAL  OF  SKIN  DISEASES.  New  (2d) 
edition.  In  one  12mo.  volume  of  560  pages,  with  40  illustrations  and 
2  plates.     Cloth,  $2.25,  net.    Just  ready. 


The  best  of  all  the  small  books  to 
recommend  to  students  and  practi- 
tioners. Probably  no  one  of  our 
dermatologists  has  had  a  wider  every- 


day clinical  experience.  His  great 
strength  is  in  diagnosis,  deselections 
of  lesions  and  especially  in  treat- 
ment.— Indiana  Medical  Journal. 


HARE  (HOBART  AMORY).  PRACTICAL  DIAGNOSIS.  THE 
USE  OF  SYMPTOMS  IN  THE  DIAGNOSIS  OF  DISEASE.  New 
(4th)  edition.  In  one  octavo  volume  of  623  pages,  with  205  engravings 
and  14  full-page  colored  plates.     Cloth,  $5.00,  net.    Just  ready. 


It  is  unique  in  many  respects,  and 
the  author  has  introduced  radical 
changes  which  will  be  welcomed  by 
all.  Anyone  who  reads  this  book 
will  become  a  more  acute  observer, 
will  pay  more  attention  to  the  simple 
yet  indicative  signs  of  disease,  and 


he  Avill  become  a  better  diagnosti- 
cian. This  is  a  companion  to  Prac- 
tical Therapeutics,  by  the  same 
author,  and  it  is  difficult  to  conceive 
of  any  two  works  of  greater  practical 
utility. — Medical  Review. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     13 

HARE  (HOB ART  AMORY).  A  TEXT-BOOK  OF  PRACTICAL 
THERAPEUTICS,  with  Special  Reference  to  the  Application  of  Reme- 
dial Measures  to  Disease  and  their  Employment  upon  a  Rational 
Basis.  With  articles  on  various  subjects  by  well-known  specialists. 
New  (7th)  and  revised  edition.  In  one  octavo  volume  of  776  pages. 
Cloth,  $3.75,  net;  leather,  $4.50,  net. 


Its  classifications  are  inimitable, 
and  the  readiness  with  which  any- 
thing can  be  found  is  the  most  won- 
derful achievement  of  the  art  of  in- 
dexing. This  edition  takes  in  all 
the  latest  discovered  remedies. — 
The  St.  Louis  Clinigue. 

The  great  value  of  the  work  lies 
in  the  fact  that  precise  indications 
for  administration  are  given.  A 
complete  index  of  diseases  and 
remedies  makes  it  an  easy  reference 


it  can  be  readily  used  in  connection 
with  Hare's  Practical  Diagnosis. 
For  the  needs  of  the  student  and 
general  practitioner  it  has  no  equal. 
— Medical  Sentinel. 

The  best  planned  therapeutic  work 
of  the  century. — American  Prac- 
titioner and  Ncivs. 

It  is  a  book  precisely  adapted  to 
the  needs  of  the  busy  practitioner, 
who  can  rely  upon  finding  exactly 
what  he  needs. —  The  National  Med- 


work.    It  has  been  arranged  so  that  I  ical  Review. 

HARE  (HOBART  AMORY)  ON  THE  MEDICAL  COMPLICA 
TIONS  AND  SEQUELiE  OF  TYPHOID  FEVER.  Octavo,  276 
pages,  21  engravings  and  two  full-page  plates.     Just  ready.     Cloth, 

$2.40,  net. 

A  very  valuable  production.    One  ,  read  with   great  profit.— C/c  re  land 
of  the  very  best   products  of   Dr.    Journal  of  Medicine. 
Hare  and  one  that  every  man  can) 

HARE  (HOBART  AMORY,  EDITOR).  A  SYSTEM  OF  PRAC- 
TICAL THERAPEUTICS.  In  a  series  of  contributions  by  eminent 
practitioners.  In  four  large  octavo  volumes  comprising  about  4500 
pages,with  about  550  engravings.  Vol.  IV.,  just  ready.  For  sale  by  sub 
scription  only.  Full  prospectus  free  on  application  to  the  Publishers 
Regular  price,  Vol.  IV.,  cloth,  $6 ;  leather,  $7 ;  half  Russia,  $8 
Price  Vol.  IV.  to  former  or  new  subscribers  to  complete  work,  cloth 
$5  ;  leather,  $6  ;  half  Russia,  $7.  Complete  work,  cloth,  $20;  leather 
$24 ;  half  Russia,  $28. 

The  great  value  of  Hare's  System  of  Practical  Therapeutics  has  led  to  a 
v.  idespread  demand  for  a  new  volume  to  represent  advances  in  treatment 
made  since  the  publication  of  the  first  three.  More  than  fulfilling  ibis 
request  the  Editor  has  secured  contributions  from  practically  a  new  corps 
ol  equally  eminent  authors,  so  that  entirely  fresh  and  original  matter  is 
ensured.  The  plan  of  the  work,  which  proved  so  successful,  has  been  fol- 
lowed  in  ibis  new  volume,  which  will  be  found  to  present  t  be  latest  devel- 
opments and  applications  of  this  most  practical  branch  of  the  medical  art. 
The  entire  System  is  an  unrivalled  encyclopaedia  on  the  practical  parts  of 
ttiedioine,  and  merits  the  great  success  it  has  wou  for  that  reason. 


14     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 


HARTSHORNE  (HENRY).  ESSENTIALS  OF  THE  PRINCIPLES 
AND  PRACTICE  OF  MEDICINE.  Fifth  edition.  In  one  12mo. 
volume,  669  pages,  with  144  engravings.     Cloth,  $2.75 . 


A  HANDBOOK  OF  ANATOMY  AND  PHYSIOLOGY.    In  one 

12mo.  volume  of  310  pages,  with  220  engravings.     Cloth,  $1.75. 

A  CONSPECTUS  OF  THE  MEDICAL  SCIENCES.    Comprising 

Manuals  of  Anatomy,  Physiology,  Chemistry,  Materia  Medica,  Prac- 
tice of  Medicine,  Surgery  and  Obstetrics.  Second  edition.  In  one  royal 
12mo.  vol.  of  1028  pages,  with  477  illus.     Cloth,  $4.25 ;  leather,  $5. 

HAYDEN  (JAMES  R.).  A  MANUAL  OF  VENEREAL  DISEASES. 
New  (2d)  edition.  In  one  12mo.  volume  of  304  pages,  with  54  en- 
gravings.    Cloth,  $1.50,  net.    Just  ready. 


It  is  practical,  concise,  definite 
and  of  sufficient  fulness  to  be  satis- 
factory.—  Chicago  Clinical  Review. 

This  work  gives  all  of  the  prac- 
tically essential  information  about 
the  three  venereal  diseases,  gon- 
orrhoea, the  chancroid  and  syphilis. 
In  diagnosis  and  treatment  it  is  par- 


ticularly thorough,  and  may  be 
relied  upon  as  a  guide  in  the  man- 
agement of  this  class  of  diseases. — 
Northwestern  Lancet. 

It  is  well  written,  up  to  date,  and 
will  be  found  very  useful. — Inter- 
national Medical  Magazine. 


HAYEM  (GEORGES)  AND  HARE  (H.  A.).  PHYSICAL  AND 
NATURAL  THERAPEUTICS.  The  Remedial  Use  of  Heat,  Elec- 
tricity, Modifications  of  Atmospheric  Pressure,  Climates  and  Mineral 
Waters.  Edited  by  Prof.  H.  A.  Hare,  M.  D.  In  one  octavo  volume 
of  414  pages,with  113  engravings.     Cloth,  $3. 


This  well-timed  up-to-date  volume 
is  particularly  adapted  to  the  re- 
quirements of  the  general  practi- 
tioner. The  section  on  mineral 
waters  is  most  scientific  and  prac- 
tical. Some  200  pages  are  given  up 
to  electricity  and  evidently  embody 
the  latest  scientific  information  on 
the  subject.  Altogether  this  work 
is  the  clearest  and  most  practical  aid 
to  the  study  of  nature's  therapeutics 
that  has  yet  come  under  our  obser- 
vation.— The  Medical   Fortnightly. 

For  many  diseases  the  most  potent 
remedies  lie  outside  of  the  materia 
medica,  a  fact  yearly  receiving  wider 


recognition.  Within  this  large 
range  of  applicability,  physical 
agencies  when  compared  with  drugs 
are  more  direct  and  simple  in  their 
results.  Medical  literature  has  long 
been  rich  in  treatises  upon  medical 
agents,  but  an  authoritative  work 
upon  the  other  great  branch  of 
therapeutics  has  until  now  been  a 
desideratum.  The  section  on  climate, 
rewritten  by  Prof.  Hare,  will,  for 
the  first  time,  place  the  abundant 
resources  of  our  country  at  the  in- 
telligent command  of  American 
practitioners.  —  The  Kansas  City 
Medical  Index. 


HERMAN  (G.  ERNEST).     FIRST  LINES  IN  MIDWIFERY.    In 

one  12mo.  vol.  of  198  pages,  with  80  engravings.     Cloth,  $1.25.     See 
Student's  Series  of  Manuals,  page  27. 


HERMANN  (L..).  EXPERIMENTAL  PHARMACOLOGY.  A  Hand- 
book of  the  Methods  for  Determining  the  Physiological  Actions  of 
Drugs.  Translated  by  Robert  Meade  Smith,  M.  D.  In  one  12mo. 
volume  of  199  pages,  with  32  engravings.    Cloth,  $1.50. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     15 


HERRICK  (JAMES  B.).     A  HANDBOOK   OF  DIAGNOSIS.     In 

one  handsome  12mo.  volume  of  429  pages,  with  80  engravings  and  2 
colored  plates.     Cloth,  $2.50. 


Excellently  arranged,  practical, 
concise,  up-to-date,  and  eminently 
well  fitted  for  the  use  of  the  prac- 
titioner as  well  as  of  the  student. — 
Chicago  3Ied.  Recorder. 

This  volume  accomplishes  its  ob- 
jects more  thoroughly  and  com- 
pletely than  any  similar  work  yet 
published.  Each  section  devoted  to 
diseases  of  special  systems  is  pre- 
ceded with  an  exposition  of  the 
methods  of  physical,  chemical  and 


microscopical  examination  to  be  em- 
ployed in  each  class.  The  technique 
of  blood  examination, including  color 
analysis,  is  very  clearly  stated. 
Uranalysis  receives  adequate  space 
and  care. — New  York  Med.  Journal. 
We  commend  the  book  not  only  to 
the  undergraduate,  but  also  to  the 
physician  who  desires  a  ready  means 
of  refreshing  his  knowledge  of  diag- 
nosis in  the  exigencies  of  professional 
life. — Memphis  Mediial  Monthly. 


HTT.T,  (BERKELEY).  SYPHILIS  AND  LOCAL  CONTAGIOUS 
DISORDERS.    In  one  8vo.  volume  of  479  pages.     Cloth,  $3.25. 

HELIilER  (THOMAS).  A  HANDBOOK  OF  SKIN  DISEASES. 
Second  edition.  In  one  royal  12mo.  volume  of  353  pages,  with  two 
plates.    Cloth,  $2.25. 

HIRST  (BARTON  C.)  AND  PDERSOL  (GEORGE  A.).  HUMAN 

MONSTROSITIES.  Magnificent  folio,  containing  220  pages  of  text 
and  illustrated  with  123  engravings  and  39  large  photographic  plates 
from  nature.  In  four  parts,  price  each,  $5.  Limited  edition.  For  sale 
by  subscription  only. 

HOBLYN  (RICHARD  D.).  A  DICTIONARY  OF  THE  TERMS 
USED  IN  MEDICINE  AND  THE  COLLATERAL  SCIENCES. 
In  one  12mo.  volume  of  520  double-columned  pages.  Cloth,  $1.50 ; 
leather,  $2. 

HODGE  (HUGH  L..).  ON  DISEASES  PECULIAR  TO  WOMEN. 
INCLUDING  DISPLACEMENTS  OF  THE  UTERUS.  Second  and 
revised  edition.    In  one  8vo.  vol.  of  519  pp.,  with  illus.     Cloth,  $4.50. 

HOFFMANN  ( FREDERICK)  AND  POWER  (FREDERICK  B. ). 

A  MANUAL  OF  CHEMICAL  ANALYSIS,  as  Applied  to  the 
Examination  of  Medicinal  Chemicals  and  their  Preparations.  Third 
edition,  entirely  rewritten  and  much  enlarged.  In  one  handsome  octavo 
volume  of  621  pages,  with  179  engravings.     Cloth,  $4.25. 

HOLMES  (TIMOTHY).  A  TREATISE  ON  SURGERY.  Its  Prin- 
ciples and  Practice.  A  new  American  from  the  fifth  English  edition. 
Edited  by  T.  PICKERING  Pick,  F.R.C.S.  In  one  handsome  octavo  vol- 
ume of  L008.pages,  with  428  engravings.     Cloth,  $G;  leather,  $7. 


—  A  SYSTFM  (»F  SFRGERY.  With  notes  and  additions  by  various 
American  authors.  Edited  by  John  If.  PACKARD,  M.D.  In  three 
very  handsome  8vo.  volumes  containing  3137  double-columned  pages, 
with  979  engravings  and  13  lithographic  plates.  Per  volume,  clotn,  $6 ; 
leather,  $7 ;  half  Russia,  $7.50.    For  tale  by  tubacription  only. 


16     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

HORNER  (WILLIAM  EL).  SPECIAL  ANATOMY  AND  HIS- 
TOLOGY. Eighth  edition,  revised  and  modified.  In  two  large  8vo. 
volumes  of  1007  pages,  containing  320  engravings.    Cloth,  $6. 


HUDSON  (A.).  LECTURES  ON  THE  STUDY  OF  FEVER.    In  one 
octavo  volume  of  308  pages.     Cloth,  $2.50. 


HUTCHISON  (ROBERT)  AND  RAINY  (HARRY).  CLINICAL 
METHODS.  A  GUIDE  TO  THE  PRACTICAL  STUDY  OF 
MEDICINE.  In  one  12mo.  volume  of  562  pages,  with  137  engrav- 
ings and  8  colored  plates.     Cloth,  $3.00. 


A  comprehensive,  clear  and  re- 
markably up-to-date  guide  to  clinical 
diagnosis.  The  illustrations  are 
plentiful  and  excellent.  As  exam- 
ples of  the  more  recent  additions  to 


medical  knowledge  which  receive 
recognition,  we  mention  Widal's 
test  for  typhoid  and  the  Neuron 
theory  of  the  nervous  system. — 
Montreal  Medical  Journal. 


HUTCHINSON  (JONATHAN).  SYPHILIS.  In  one  pocket-size  12mo. 
volume  of  542  pages,  with  8  chromo-lithographic  plates.  Cloth,  $2.25. 
See  Series  of  Clinical  Manuals,  p.  25. 


HYDE  ( JAMES  NEVINS).  A  PRACTICAL  TREATISE  ON  DIS- 
EASES OF  THE  SKIN.  New  (4th)  edition,  thoroughly  revised. 
In  one  octavo  volume  of  815  pages,  with  110  engravings  and  12  full- 
page  plates,  4  of  which  are  colored.     Cloth,  $5.25 ;   leather,  $6.25. 


This  edition  has  been  carefully  re- 
vised, and  every  real  advance  has 
been  recognized.  The  work  answers 
the  needs  of  the  general  practitioner, 
the  specialist,  and  the  student. — The 
Ohio  Med.  Jour. 

A  treatise  of  exceptional  merit 
characterized  by  conscientious  care 
and  scientific  accuracy. — Buffalo 
Med.  Journal. 

A  complete  exposition  of  our 
knowledge  of  cutaneous  medicine  as 
it  exists  to-day.  The  teaching  in- 
culcated throughout  is  sound  as  well 


as  practical. — The  American  Jour- 
nal of  the  Medical  Sciences. 

It  is  the  best  one-volume  work 
that  we  know.  The  student  who 
gets  this  book  will  find  it  a  useful 
investment,  as  it  will  well  serve  him 
when  he  goes  into  practice. —  Vir- 
ginia Medical  Semi- Monthly. 

A  full  and  thoroughly  modern 
text-book  on  dermatology.  —  The 
Pittsburg  Medical  Review. 

It  is  the  most  practical  hand- 
book on  dermatology  with  which  we 
are  acquainted. — The  Chicago  Med- 
ical Recorder. 


JACKSON  (GEORGE  THOMAS).  THE  READY-REFERENCE 
HANDBOOK  OF  DISEASES  OF  THE  SKIN.  New  (3d)  edition. 
In  one  12mo.  volume  of  637  pages,  with  75  illustrations  and  a  colored 
plate.    Just  ready.     Cloth,  $2.50,  net. 


As  a  student's  manual,  it  may  be 
considered  beyond  criticism.  The 
book  is  singularly  full. — St.  Louis 
Medical  and  Surgical  Journal. 


Without  doubt  forms  one  of  the 
best  guides  for  the  beginner  in  der- 
matology that  is  to  be  found  in  the 
English  language. — Medicine. 


JAMD3SON  (W.  ALLAN).  DISEASES  OF  THE  SKIN.  Third 
edition.  In  one  octavo  volume  of  656  pages,  with  1  engraving  and  9 
double-page  chromo-lithographic  plates.    Cloth,  $6. 


Lea  Bbothebs  &  Co.,  Philadelphia  and  New  York.     17 

JEWETT  (CHARLES).  ESSENTIALS  OF  OBSTETRICS.  In  one 
12mo.  volume  of  356  pages,  with  80  engravings  and  3  colored  plates. 
Cloth,  $2.25.    Just  ready. 


An  exceedingly  useful  manual  for 
student  and  practitioner.  The  au- 
thor has  succeeded  unusually  well 
in  condensing  the  text  and  in  arrang- 


ing it  in  attractive  and  easily  tangi- 
ble form.  The  book  is  well  illus- 
trated throughout. — Nashville  Jour, 
of  Medicine  and  Surgery. 


THE  PRACTICE  OF  OBSTETRICS.     By   American    Authors. 

One  large  octavo  volume  of  763  pages,  with  441  engravings  in  black 
and  colors,  and  22  full-page  colored  plates.  Just  ready.  Cloth, 
$5.00,  net;  leather,  $6.00,  net. 

A  clear  and  practical  treatise  upon  I  the  book  abounds.  The  work  is 
obstetrics  by  well-known  teachers  of  sure  to  be  popular  with  medical 
the  subject.  A  special  feature  of !  students,  as  well  as  being  of  extreme 
this  work  would  seem  to  be  the  I  value  to  the  practitioner.  —  The 
excellent  illustrations    with   which  |  Medical  Age. 

JONES  (C.  HANDF1ELD).  CLINICAL  OBSERVATIONS  ON 
FUNCTIONAL  NERVOUS  DISORDERS.  Second  American  edi- 
tion.   In  one  octavo  volume  of  340  pages.     Cloth,  $3.25. 

JUIiER  (HENRY).  A  HANDBOOK  OF  OPHTHALMIC  SCIENCE 
AND  PRACTICE.      Second  edition.  In  one  octavo  volume  of  549 

J  ages,  with  201  engravings,  17  chromo-lithographic  plates,  test-types  of 
aeger  and  Snellen,  and  Holmgren's  Color-Blindness  Test.     Cloth, 
$5.50 ;  leather,  $6.50. 

The  volume  is  particularly  rich  in  |  color  blindness,   etc.    The   sections 
matter  of  practical  value,  such   as  j  devoted  to  treatment  are  singularly 
directions    for    diagnosing,    use    of   full  and  concise. — Medical  Age. 
instruments,  testing  for  glasses,  for  | 

KING  (A.  F.  A.).  A  MANUAL  OF  OBSTETRICS.  Seventh  edition. 
In  one  12mo.  volume  of  573  pages,  with  223  illustrations.  Cloth, 
$2.50. 

From  first  to  finish  it  is  thoroughly  cyclopedias.  The  well-arranged 
practical,  concise  in  expression,  well  i  index  renders  the  book  useful  to 
illustrated,  and  includes  a  statement  !  the  practitioner  who  is  in  haste  to 
of  nearly  every  fact  of  importance  '  refresh  his  memory.  —  Virginia 
discussed  in    obstetric    treatises  or  !  Medical  Semi-Monthly. 

KIRK  (EDWARD  C).  OPERATIVE  DENTISTRY.  Handsome 
octavo  of  700  pages,  with  751  illustrations.  Just  ready.  See  American 
Text-Books  of  Dentistry,  page  2. 

We  have  only  the  highest  praise  f  tempted.     We  can  heartily  recom- 
for  this  valuable  work.   It  is  replete    mend    it    to    the    profession.—  Tin 
in  every  particular,  and  surpasses    OMo  Dental  Journal. 
anything  of  the  kind  heretofore  at- 

KLEIN  (E.).  ELEMENTS  OF  HISTOLOGY.  New  (5th)  edition.  In 
one  12mo.  volume  of  506  pages,  with  296  engravings.  Just  ready. 
Cloth,  $2.0u,  net.     See  Student's  Series  of  Manuals,  page  27. 

It  is  the  most   complete  and  con-  This  work  deservedly  occupies  a 

cise  work  of  the  kind  that  has  yet  first  place  as  a  text-book  on    his- 

emanated  from  the  press. —  The  Med-  tology. — Canadian  Practitioner, 
ical  Age. 


18     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

LANDIS  (HENRY  G.).  THE  MANAGEMENT  OF  LABOR.  In  one 

handsome  12mo.  volume  of  329  pages,  with  28  illus.   Cloth,  $1.75. 

LA  ROCHE  (R.).  YELLOW  FEVER.  In  two  8vo.  volumes  of  1468 
pages.    Cloth,  $7. 

LAURENCE  (J.  Z.)  AND  MOON  (ROBERT  C).  A  HANDY- 
BOOK  OF  OPHTHALMIC  SURGERY.  Second  edition.  In  one 
octavo  volume  of  227  pages,  with  66  engravings.    Cloth,  $2.75. 

LEA'S  SERIES  OF  POCKET  TEXT-BOOKS,  edited  by  Bern 
B.  Gallaudet,  M.  D.  Covering  the  entire  field  of  Medicine  in  a 
series  of  16  very  handsome  cloth-bound  12mo.  volumes  of  350-450 
pages  each,  profusely  illustrated.  Compendious,  clear,  trustworthy  and 
modern,  and  issued  at  the  very  moderate  price  of  $1.50,  net,  per 
volume.     The  following  volumes  constitute  the  series. 

Coates'  Bacteriology  and  Hygiene.  Beockway's  Anatomy.  Collins 
and  Rockwell's  Physiology.  Martin  and  Rockwell's  Chemistry 
and  Physics.  Nichols  and  Vale's  Histology  and  Pathology. 
Schleif's  Materia  Medica,  Therapeutics,  Medical  Latin,  etc.  Mals- 
bary's  Practice  of  Medicine.  Collins'  Diagnosis.  Potts'  Nervous 
and  Mental  Diseases.  Gallaudet's  Surgery.  Likes'  Genito- 
urinary and  Venereal  Diseases.  Geindon's  Dermatology.  Ballen- 
ger  and  Wippeen's  Diseases  of  the  Eye,  Ear,  Throat  and  Nose. 
Evans'  Obstetrics.  Ceockett's  Gynecology.  Tuttle's  Diseases  of 
Children. 

For  separate  notices  see  under  various  authors'  names. 

LEA  (HENRY  C).  A  HISTORY  OF  AURICULAR  CONFESSION 
AND  INDULGENCES  IN  THE  LATIN  CHURCH.  In  three 
octavo  volumes  of  about  500  pages  each.     Per  volume,  cloth,  $3.00. 

CHAPTERS  FROM  THE  RELIGIOUS  HISTORY  OF  SPAIN; 

CENSORSHIP  OF  THE  PRESS;  MYSTICS  AND  ILLUMIN  ATI - 
THE  ENDEMONIADAS ;  EL  SANTO  NlftO  DE  LA  GUARDIA ; 
BRIANDA  DE  BARDAXI.    12mo.,  522  pages.    Cloth,  $2.50. 

FORMULARY  OF  THE   PAPAL  PENITENTIARY.    In  one 

octavo  volume  of  221  pages,  with  frontispiece.     Cloth,  $2.50. 

SUPERSTITION  AND  FORCE ;  ESSAYS  ON  THE  WAGER 

OF  LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL  AND 
TORTURE.  Fourth  edition,  thoroughly  revised.  In  one  hand- 
some royal  12mo.  volume  of  629  pages.     Cloth,  $2.75. 

STUDIES  IN  CHURCH  HISTORY.    The  Rise  of  the  Temporal 

Power — Benefit  of  Clergy — Excommunication.  New  edition.  In  one 
handsome  12mo.  volume  of  605  pages.    Cloth,  $2.50. 

AN  HISTORICAL  SKETCH  OF  SACERDOTAL  CELIBACY 


IN  THE  CHRISTIAN  CHURCH.    Second  edition.    In  one  hand- 
some octavo  volume  of  685  pages.    Cloth,  $4.50. 

LEHMANN  (C.  Q.).    A  MANUAL  OF  CHEMICAL  PHYSIOLOGY. 
In  one  8vo.  volume  of  327  pages,  with  41  engravings.     Cloth,  $2.25. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  \ork.     19 


LIKES  (SYLVAN  H.).  A  POCKET  TEXT-BOOK  OF  GENITO- 
URINARY AND  VENEREAL  DISEASES.  In  one  handsome 
12mo.  volume  of  about  350  pages,  with  many  illustrations.  Shortly. 
Cloth,  $1.50,  net.  Lra's  Series  of  Pocket  Text-books,  edited  by  Bekn 
B.  Gallaudet,  M.  D.     See  page  18. 

LOOMIS  (ALFRED  L.)  AND  THOMPSON  (W.  GILMAN, 
EDITORS).  A  SYSTEM  OF  PRACTICAL  MEDICINE.  In 
Contributions  by  Various  American  Authors.  In  four  very  hand- 
some octavo  volumes  of  about  900  pages  each,  fully  illustrated  in 
in  black  and  colors.  Complete  work  noiu  ready.  Per  volume,  cloth, 
$5 ;  leather,  $6  ;  half  Morocco,  $7.  For  sale  by  subscription  only. 
Full  prospectus  free  on  application  to  the  Publishers.  See  American 
System  of  Practical  Medicine,  page  2. 


LUFF  (ARTHUR  P.). 

Students  of  Medicine, 
engravings.     Cloth,  $2. 


MANUAL  OF  CHEMISTRY,  for  the  use  of 

In  one  12mo.  volume  of  522  pages,   with  36 
See  Student's  Series  of  3Ianuals,  page  27. 


LYMAN  (HENRY  M.).    THE  PRACTICE  OF  MEDICINE.    In  one 

very  handsome  octavo  volume  of  925  pages,  with  170  engravings. 
Cloth,  $4.75 ;  leather,  $5.75. 

Complete,  concise,  fully  abreast  of  Practical,  systematic,  complete  and 
the  times  and  needed  by  all  students  \  well  balanced. — Chicago  Med.  Re- 
and  practitioners. —  Univ.  Med.  3 fag.  '  corder. 

An  exceedi  ngly  valuable  text-book.  ' 


LYONS  (ROBERT  D. 

volume  of  362  pages. 


A  TREATISE  ON  FEVER. 
Cloth,  $2.25. 


In  one  octavo 


MACKENZIE  (JOHN  NOLAND).  ON  THE  NOSE  AND  THROAT. 
Handsome  octavo,  about  600  pages,  richly  illustrated.     Preparing. 


MAISCH  (JOHN  M.).  A  MANUAL  OF  ORGANIC  MATERIA 
MEDICA.  New  (7th)  edition,  thoroughly  revised  by  H.  C.  C.  Maisch, 
Ph.  G.,  Ph.  D.  In  one  very  handsome  12mo.  volume  of  512  pages,  with 
285  engravings.    Just  ready.    Cloth,  $2.50,  net. 


Used  as  text-book  in  every  college 
of  pharmacy  in  the  Qnitea  States 
and  recommended  in  medical  col- 
leges.— Amrriran  Therapist. 

Noted  on  both  sides  of  the  Atlantic 
and  esteimed  as  much  in  Germany  as 


in  America.  The  work  has  no  equal. 

Dominion   ilr<l.  Monthly. 

The  best  handbook  upon  phar- 
macognosy  of  any  published  in  this 
country. — Boston  Med.  &  S»r.  Jonr. 


20    Lea  Brothebs  &  Co.,  Philadelphia  and  New  Yobk. 

MALSBARY  (GEORGE  E.).  A  POCKET  TEXT-BOOK  OF 
THEORY  AND  PRACTICE  OF  MEDICINE.  In  one  handsome 
12mo.  volume  of  about  350  pages.  Cloth,  $1.50,  net.  Shortly.  Lea's 
Series  of  Pocket  Text-books,  edited  by  Bern  B.  Gallaudet,  M.  D. 
See  page  18. 

MANUALS.  See  Student's  Quiz  Series,  page  27,  Student's  Series  of 
Manuals,  page  27,  and  Series  of  Clinical  Manuals,  page  25. 

MARSH  (HOWARD).  DISEASES  OF  THE  JOINTS.  In  one  12mo. 
volume  of  468  pages,  with  64  engravings  and  a  colored  plate.  Cloth,  $2. 
See  Series  of  Clinical  Manuals,  page  25. 

MARTIN  (EDWARD).  A  MANUAL  OF  SURGICAL  DIAGNOSIS. 
In  one  12mo.  volume  of  about  400  pp.,  fully  illustrated.     Preparing. 

MARTIN  (WALTON)  AND  ROCKWELL,  (WM.  H).  A  POCKET 
TEXT-BOOK  OF  CHEMISTRY  AND  PHYSICS.  In  one  hand- 
some 12mo.  volume  of  about  350  pages,  with  many  illustrations.  Cloth, 
$1.50,  net.  Shortly.  Lea's  Series  of  Pocket  Text-books,  edited  by 
Bern  B.  Gallaudet,  M.  D.    See  page  18. 

MAY  (C.  H.).  MANUAL  OF  THE  DISEASES  OF  WOMEN.  For 
the  use  of  Students  and  Practitioners.  Second  edition,  revised  by  L. 
S.  Rau,  M.  D.  In  one  12mo.  volume  of  360  pages,  with  31  engrav- 
ings.    Cloth,  $1.75. 

MEDICAL  NEWS  POCKET  FORMULARY,  see  page  32. 


MITCHELL  (S.  WEIR).  CLINICAL  LESSONS  ON  NERVOUS 
DISEASES.  In  one  12mo.  volume  of  299  pages,  with  19  engravings 
and  2  colored  plates.  Cloth,  $2.50.  Of  the  hundred  numbered  copies 
with  the  Author's  signed  title  page  a  few  remain ;  these  are  offered 
in  green  cloth,  gilt  top,  at  $3.50,  net. 


The  book  treats  of  hysteria,  recur- 
rent melancholia,  disorders  of  sleep, 
choreic  movements,  false  sensations 
of  cold,  ataxia,  hemiplegic  pain, 
treatment  of  sciatica,  erythromelal- 
gia,  reflex  ocularneurosis,  hysteric 


contractions,  rotary  movements  in 
the  feeble  minded,  etc.  Few  can 
speak  with  more  authority  than  the 
author. —  The  Journal  of  the  Ameri- 
can Medical  Association. 


MITCHELL  (JOHN  K.).  REMOTE  CONSEQUENCES  OF  IN- 
JURIES OF  NERVES  AND  THEIR  TREATMENT.  In  one 
handsome  12mo.  volume  of  239  pages, with  12  illustrations.  Cloth,  $1.75. 


Injuries  of  the  nerves  are  of  fre- 
quent occurrence  in  private  practice, 
and  often  the  cause  of  intractable 
and  painful  conditions,  conse- 
quently this  volume  is  of  especial 
interest.    Doctor  Mitchell  has  had 


access  to  hospital  records  for  the  last 
thirty  years,  as  well  as  to  the 
government  documents,  and  has 
skilfully  utilized  his  opportunities. 
— The  Med.  Age. 


MORRIS  (MALCOLM).  DISEASES  OF  THE  SKIN.  New  (2d) 
edition.  In  one  12mo.  volume  of  601  pages,  with  10  chromo-litho- 
graphic  plates  and  26    engravings.     Cloth,  $3.25,   net.    Just  ready. 

MULLER  (J.).  PRINCIPLES  OF  PHYSICS  AND  METEOROL- 
OGY.   In  one  large  8vo.  vol.  of  623  pages,  with  538  cuts.  Cloth,  $4.50. 


Lea  Beothees  &  Co.,  Philadelphia  and  New  Yoek.     21 


MTTSSER  (JOHN  H.).   A  PKACTICAL  TREATISE  ON  MEDICAL 
DIAGNOSIS,  for  Students  and  Physicians.    New  (3d)  edition,  thor- 
oughly revised.    In  one  octavo  volume  of  about  1000  pages,  with  about 
220  engravings  and  48  full-page  colored  plates.    In  press. 
Notices  of  previous  edition  are  appended. 


We  have  no  work  of  equal  value 
in  English.  —  University  Medical 
Magazine. 

His  descriptions  of  the  diagnostic 
manifestations  of  diseases  are  accu- 
rate. This  work  will  meet  all  the 
requirements  of  student  and  physi- 
cian.— The  Medical  News. 

From  its  pages  may  be  made  the 
diagnosis  of  every  malady  that 
afflicts  the  human  body,  including 
those  which  in  general  are  dealt 
with  only  by  the  specialist. — North- 
western Lancet. 


It  so  thoroughly  meets  the  precise 
demands  incident  to  modern  research 
that  it  has  been  adopted  as  a  leading 
text-book  by  the  medical  colleges 
of  this  country. — North  American 
Practitioner. 

Occupies  the  foremost  place  as  a 
thorough,  systematic  treatise. —  Ohio 
Medical  Journal. 

The  best  of  its  kind,  invaluable  to 
the  student,  general  practitioner  and 
teacher. — Montreal  Medical  Journal. 


NATIONAL  DISPENSATORY.  See  Stille,  Maisch  &  Caspari,  p.  27. 


NATIONAL  FORMULARY. 

Dispensatory,  page  27. 


See  Stille,  Maisch  &  Caspari' s  National 


NATIONAL  MEDICAL  DICTIONARY.    See  Billings,  page  4. 

NETTLESHD?  (E.).  DISEASES  OF  THE  EYE.  New  (5th)  American 
from  sixth  English  edition,  thoroughly  revised.  In  one  12mo.  volume 
of  521  pages,  with  161  engravings,  and  2  colored  plates,  test-types, 
formulae  and  color-blindness  test.     Cloth,  $2.25.    Just  ready. 


By  far  the  best  student's  text-book 
on  the  subject  of  ophthalmology  and 
is  conveniently  and  concisely  ar- 
ranged.— The  Clinical  Review. 

It  has  been  conceded  by  ophthal- 
mologists generally  that  this  work 
for  compactness,  practicality  and 
clearness    has  no  superior    in   the 


English     language.  —  Journal      of 
Medicine  and  Science. 

The  present  edition  is  the  result 
of  revision  both  in  England  and 
America,  and  therefore  contains  the 
latest  and  best  ophthalmological 
ideas  of  both  continents. —  The  Phy- 
sician and  Surgeon. 


NICHOLS  (JOHN  B.)  AND  VALE  (F.  P.).  A  POCKET  TEXT- 
BOOK  OF  HISTOLOGY  AND  PATHOLOGY.  In  one  handsome 
12mo.  volume  of  about  350  pages,  with  many  illustrations.  /,/  press. 
Cloth,  $1.50,  net.  Lea's  Series  of  Pocket  Text-books,  edited  hy  Bern 
B.  GALLATJDET,  M.  D.     See  page  18. 

NOKRIS  (WM.  F.)  AND  OLIVER  (CHAS.  A.).  TEXT-BOOK  OF 
OPHTHALMOLOGY.  In  one  octavo  volume  of  641  pages,  with  357 
engravings  and  5  colored  plates.     Cloth,  $5  ;  leather,  $6. 

A  safe  and  admirable  guide,  well  '  best,  the  safest  and  the  most  compre- 
qualified  to  furnish  a  working  ■  hensive  volume  upon  the  subject  thai 
knowledge    of     ophthalmology. —    has  ever  been  offered  to  the    \  imi- 

of 


Johns  Hopkins  Hospital  Bulletin 

It   is  practical  in   its   teachings. 
We  unreservedly  endorse  it  as  the 


ican    medical     public. — Annals 
Ophthalmology  and  Otology. 


22     Lea  Brothebs  &  Co.,  Philadelphia  and  New  York. 

OWEN  (EDMUND).  SURGICAL  DISEASES  OF  CHILDREN. 
In  one  12mo.  volume  of  525  pages,  with  85  engravings  and  4  colored 
plates.     Cloth,  $2.     See  Series  of  Clinical  Manuals,  page  25. 


PARK  (ROSWELL).  A  TREATISE  ON  SURGERY  BY  AMERI- 
CAN AUTHORS.  New  and  condensed  edition.  In  press.  In  one 
royal  octavo  volume  of  about  1250  pages,  with  about  1000  engravings 
and  many  full-page  plates.  JE£?"This  work  is  also  published  in  a 
larger  edition,  comprising  two  volumes.  Volume  I.,  General  Surgery, 
799  pages,  with  356  engravings  and  21  full-page  plates,  in  colors  and 
monochrome.  Volume  II.,  Special  Surgery,  800  pages,  with  430  engra- 
vings and  17  full-page  plates,  in  colors  and  monochrome.  Per  volume, 
cloth,  $4.50 ;  leather,  $5.50.    Net. 


The  work  is  fresh,  clear  and  practi- 
cal, covering  the  ground  thoroughly 
yet  briefly,  and  well  arranged  for 
rapid  reference,  so  that  it  will  be  of 
special  value  to  the  student  and  busy 

Eractitioner.  The  pathology  is 
road,  clear  and  scientific,  while  the 
suggestions  upon  treatment  are 
clear-cut,  thoroughly  modern  and 
admirably  resourceful. — Johns  Hop- 
kins Hospital  Bulletin. 

The  latest  and  best  work  written 
upon  the  science  and  art  of  surgery. 
Columbus  Medical  Journal. 

The  illustrations  are  almost  en- 
tirely new  and  executed  in  such  a 


way  that  they  add  great  force  to  the 
text. — The  Chicago  Medical  Re- 
corder. 

The  various  writers  have  em- 
bodied the  teachings  accepted  at 
the  present  hour. — The  North  Amer- 
ican Practitioner. 

Both  for  the  student  and  practi- 
tioner it  is  most  valuable.  It  is 
thoroughly  practical  and  yet  thor- 
oughly scientific. — Medical  News. 

A  truly  modern  surgery,  not  only 
in  pathology,  but  also  in  sound 
surgical  therapeutics.  —  New  Or- 
leans Med.  and  Surgical  Journal. 


PARK  (WILLIAM  H.).     BACTERIOLOGY  IN  MEDICINE  AND 

SURGERY.     12mo.,  about  550  pages,  fully  illustrated.     In  press. 

PARRY  (JOHN  S.).  EXTRA-UTERINE  PREGNANCY,  ITS 
CLINICAL  HISTORY,  DIAGNOSIS,  PROGNOSIS  AND  TREAT- 
MENT.    In  one  octavo  volume  of  272  pages.    Cloth,  $2.50. 


PARVIN  (THEOPHILUS).  THE  SCIENCE  AND  ART  OF  OB- 
STETRICS. Third  edition.  In  one  handsome  octavo  volume  of 
677  pages,  with  267  engravings  and  2  colored  plates.  Cloth,  $4.25 ; 
leather,  $5.25. 


In  the  foremost  rank  among  the 
most  practical  and  scientific  medical 
works  of  the  day. — Medical  News. 

It  ranks  second  to  none  in  the 
English  language. — Annals  of  Gyne- 
cology and  Pediatry. 

The  book  is  complete  in  every  de- 
partment, and  contains  all  the  neces- 
sary detail  required  by  the  modern 


practising  obstetrician.  —  Interna- 
tional Medical  Magazine. 

Parvin's  work  is  practical,  con- 
cise and  comprehensive.  We  com- 
mend it  as  first  of  its  class  in  the 
English  language. — Medical  Fort- 
nightly. 

It  is  an  admirable  text-book  in 
every  sense  of  the  word. — Nashville 
Journal  of  Medicine  and  Surgery. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     23 


PEPPER'S  SYSTEM  OF  MEDICINE.    See  page  3. 

PEPPER  (A.  J.).     FORENSIC  MEDICINE.    In  press.    See  Student's 
Series  of  Manuals,  page  27. 

SURGICAL  PATHOLOGY.     In  one  12mo.  volume  of  511  pages, 


with  81  engravings.   Cloth,  $2.   See  Student's  Series  of  Manuals,  p.  27 

PICK  (T.  PICKERING).      FRACTURES  AND  DISLOCATIONS. 

In  one  12mo.  volume  of  530  pages,  with  93  engravings.      Cloth,  $2. 
See  Series  of  Clinical  Manuals,  page  25. 

PLAYFAIR  (W.  S.).  A  TREATISE  ON  THE  SCIENCE  AND 
PRACTICE  OF  MIDWIFERY.  Seventh  American  from  the  ninth 
English  edition.  In  one  octavo  volume  of  700  pages,  with  207 
engravings  and  7  plates.     Cloth,  $3.75  net;  leather,  $4.75,  net.    Just 


ready, 

In  the  numerous  editions  which 
have  appeared  it  has  been  kept  con- 
stantly in  the  foremost  rank.  It  is 
a  work  which  can  be  conscientiously- 
recommended  to  the  profession. — 
The  Albany  Medical  Annals. 

This  work  must  occupy  a  fore- 
most place  in  obstetric  medicine  as 
a  safe  guide  to  both  student  and 


obstetrician.  It  holds  a  place  among 
the  ablest  English-speaking  authori- 
ties on  the  obstetric  art. — Buffalo 
Medical  and  Surgical  Journal. 

An  epitome  of  the  science  .  and 
practice  of  midwifery,  which  em- 
bodies all  recent  advances.  —  The 
Medical  Fortnightly. 


THE  SYSTEMATIC  TREATMENT  OF  NERVE  PROSTRA- 
TION AND  HYSTERIA.  In  one  12mo.  volume  of  97  pages. 
Cloth,  $1. 

POCKET  FORMULARY,  see  page  32. 

POCKET  TEXT-BOOKS,  see  page  18. 

POLITZER  (ADAM).  A  TEXT-BOOK  OF  THE  DISEASES  OF  THE 
EAR  AND  ADJACENT  ORGANS.  Second  American  from  the 
third  German  edition.  Translated  by  Oscar  Dodd,  M.  D.,  and 
edited  by  Sir  William  Dalby,  F.  R.  C.  S.  In  one  octavo  volume  of 
748  pages,  with  330  original  engravings.     Cloth,  $5.50. 

The  anatomy  and  physiology  of  i  ment  are  clear  and  reliable.  We 
each  part  of  the  organ  of  hearing  can  confidently  recommend  it,  for  it 
are  carefully  considered,  and  then  !  contains  all  that  is  known  upon  the 
follows  an  enumeration  of  the  dis- 1  subject. — London  Lancet. 
eases  to  which  that  special  part  of  A  safe  and  elaborate  guide  into 
the  auditory  apparatus  is  especially  ,  every  part  of  otology. — American 
liable.     The   indications    for  treat-    Journal  of  the  Medical  Sciences. 

POTTS  (CHARLES  S.).  A  POCKET  TEXT-BOOK  OF  NERVOUS 
AND  MENTAL  DISEASES.  In  <>ne  handsome  12mo.  volume  of 
alioui  150  pages.  I  loth,  $1.50,  net.  Shortly.  Lea's  Series  of  Pocket 
Textbooks,  edited hy  Bern  B.  Gallaudet,  M.  I).    See  paw  18. 

PROGRESSIVE   MEDICINE,  see  page  32. 

PURDY  (CHARLES  WA  BRIGHT'S  DISEASE  AND  ALLIED 
AFFECTIONS  OF  THE  KIDNEY.  In  one  octavo  volume  of  288 
pages,  with  18  engravings.     Cloth,  $2. 


24    Lea  Brothkes  &  Co.,  Philadelphia  and  New  York. 


PYE-SMITH  (PHILIP  H.).  DISEASES  OF  THE  SKIN.  In  one 
12mo.  vol.  of  407  pp.,  with  28  illus.,  18  of  which  are  colored.  Cloth,  $2. 

QUIZ  SERIES.     See  Student's  Quiz  Series,  page  27. 

RALFE    (CHARLES  H.).      CLINICAL     CHEMISTRY.     In   one 

12mo.  volume  of  314  pages,  with  16  engravings.     Cloth,  $1.50.     See 
Student's  Series  of  Manuals,  page  27. 

RAMSBOTHAM  (FRANCIS  H.).  THE  PRINCIPLES  AND  PRAC- 
TICE OF  OBSTETRIC  MEDICINE  AND  SURGERY.     In  one 

imperial  octavo  volume  of  640  pages,  with  64  plates  and  numerous 
engravings  in  the  text.     Strongly  bound  in  leather,  $7. 

REICHERT  (EDWARD  T.).  A  TEXT-BOOK  ON  PHYSIOLOGY. 
In  one  handsome  octavo  volume  of  about  800  pages,  richly  illustrated. 
Preparing. 

REMSEN  (IRA).  THE  PRINCIPLES  OF  THEORETICAL  CHEM- 
ISTRY. New  (5th)  edition,  thoroughly  revised.  In  one  12mo.  vol- 
ume of  326  pages.     Cloth,  $2. 


A  clear  and  concise  explanation 
of  a  difficult  subject.  We  cordially 
recommend  it. —  The  London  Lancet. 

The  book  is  equally  adapted  to  the 
student  of  chemistry  or  the  practi- 
tioner who  desires  to  broaden  his 
theoretical  knowledge  of  chemistry. 
— New  Orleans  Med.  and  Surg.  Jour. 

The  appearance  of  a  fifth  edition 
of  this  treatise  is  in  itself  a  guarantee 


that  the  work  has  met  with  general 
favor.  This  is  further  established 
by  the  fact  that  it  has  been  trans- 
lated into  German  and  Italian.  The 
treatise  is  especially  adapted  to  the 
laboratory  student.  It  ranks  unusu- 
ally high  among  the  works  of  this 
class.  This  edition  has  been  brought 
fully  up  to  the  times. — American 
Medico-Surgical  Bulletin. 


RICHARDSON  (BENJAMIN  WARD).  PREVENTIVE  MEDI- 
CINE.    In  one  octavo  volume  of  729  pages.     Cloth,  $4 ;  leather,  $5. 

ROBERTS  (JOHN  B.).  THE  PRINCIPLES  AND  PRACTICE  OF 
MODERN  SURGERY.  New  (2d)  edition.  In  one  octavo  volume  of 
about  800  pages,  with  about  500  engravings.    Shortly. 


THE  COMPEND   OF  ANATOMY.     For  use  in  the  Dissecting 

Room  and  in  preparing  for  Examinations.     In  one  16mo.  volume  of 
196  pages.    Limp  cloth,  75  cents. 

ROBERTS  (SIR  WDLLIAM).  A  PRACTICAL  TREATISE  ON 
URINARY  AND  RENAL  DISEASES,  INCLUDING  URINARY 
DEPOSITS.  Fourth  American  from  the  fourth  London  edition.  In 
one  very  handsome  8vo.  vol.  of  609  pp.,  with  81  illus.     Cloth,  $3.50. 

ROBERTSON  (J.  MCGREGOR).  PHYSIOLOGICAL  PHYSICS. 
In  one  12mo.  volume  of  537  pages,  with  219  engravings.  Cloth,  $2. 
See  Student's  Series  of  Manuals,  page  27. 

ROSS  (JAMES).  A  HANDBOOK  OF  THE  DISEASES  OF  THE 
NERVOUS  SYSTEM.  In  one  handsome  octavo  volume  of  726  pages, 
with  184  engravings.     Cloth,  $4.50 ;  leather,  $5.50. 


SAVAGE  (GEORGE  H.).  INSANITY  AND  ALLIED  NEUROSES, 
PRACTICAL  AND  CLINICAL.  In  one  12mo.  volume  of  551  pages, 
with  18fctypical  engravings.  Cloth,  $2.  See  Series  of  Clinical  Man- 
uals,  page  25. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     25 

SCHAFER  (EDWARD  A.).  THE  ESSENTIALS  OF  HISTOL- 
OGY. DESCRIPTIVE  AND  PRACTICAL.  For  the  use  of  Students. 
New  (5th)  edition.  In  one  handsome  octavo  volume  of  359  pages, 
with  392  illustrations.     Cloth,  $3.00,  net.    Just  ready. 


Nowhere  else  will  the  same  very- 
moderate  outlay  secure  as  thoroughly 
useful  and  interesting  an  atlas  of 
structural  anatomy. — The  American 
Journal  of  the  Medical  Sciences. 


The  most  satisfactory  elementary 
text-book  of  histology  in  the  Eng- 
lish language. — The  Boston  Med.  and 
Sur.  Jour. 


—  A  COURSE  OF  PRACTICAL  HISTOLOGY.    New  (2d)  edition. 
In  one  12mo.  volume  of  307  pages,  with  59  engravings.   Cloth,  $2.25. 


The  book  very  nearly  approaches 
perfection.  Methods  are  given  with 
an  accuracy  of  detail  and  prevision 
of  difficulties  which  can  hardly  be 


overpraised.  It  bears  eloquent  tes- 
timony to  the  wide  knowledge  and 
untiring  industry  of  its  author. — 
The  Scottish  Med.  and  Surg.  Jour. 


SCHLEIF  (WILLIA3I).  MATERIA  MEDICA,  THERAPEUTICS, 
PRESCRIPTION  WRITING,  MEDICAL  LATIN,  ETC.  12mo., 
352  pages.  Cloth,  $1.50,  net.  Just  ready.  Zea's  Series  of  Pocket 
Text-books.    Edited  by  Been  B.  Gallaedet,  M.  D.    See  page  IS. 

SOHMITZ  AND  ZUMPT'S  CLASSICAL  SERIES.  Advanced 
Latin  Exercises.  Cloth,  60  cts.  Schmidt's  Elementary  Latin  Exer- 
cises. Cloth,  50  cents.  Sallust.  Cloth,  60  cents.  Nepos.  Cloth,  60 
cents.     Virgil.     Cloth,  85  cents.     Curtius.     Cloth,  80  cents. 

SCHOFEELD    (ALFRED    T.).      ELEMENTARY    PHYSIOLOGY 

FOR  STUDENTS.        In  one  12mo.  volume  of  380  pages,  with  227 
engravings  and  2  colored  plates.     Cloth,  $2. 

SCHRED3ER  (JOSEPH).  A  MANUAL  OF  TREATMENT  BY 
MASSAGE  AND  METHODICAL  MUSCLE  EXERCISE.  Octavo 
volume  of  274  pages,  with  117  engravings. 

SENN  (NICHOLAS).  SURGICAL  BACTERIOLOGY.  Second  edi- 
tion. In  one  octavo  volume  of  268  pages,  with  13  plates,  10  of  which 
are  colored,  and  9  engravings.     Cloth,  $2. 

SERIES  OF  CLINICAL  MANUALS.  A  Series  of  Authoritative 
Monographs  on  Important  Clinical  Subjects,  in  12mo.  volumes  of  about 
550  pages,  well  illustrated.  The  following  volumes  are  now  ready : 
Yeo  on  Food  in  Health  and  Disease,  new  (2d)  edition,  $2.50;  Carter 
and  Frost's  Ophthalmic  Surgery,  $2.25 ;  Hutchinson  on  Syphilis, 
$2.25;  Marsh  on  Diseases  of  the  Joints,  $2;  Owen  on  Surgical  Dis- 
eases of  Children,  $2;  Pick  on  Fractures  and  Dislocations,  $2;  Savage 
on  Insanity  and  Allied  Neuroses,  $2. 
For  separate  notices,  see  under  various  authors'  names. 

SEREES  OF  STUDENT'S  MANUALS.     See  page  27. 

SIMON  (CHARLES  E.).  CLINICAL  DIAGNOSIS,  BY  MICRO- 
SCOPICAL AND  CHEMICAL  METHODS.  New  (2d)  edition.  In 
one  very  handsome  octavo  volume  of  530  pages,  with  135  engravings 
and  14  full-page  colored  plates.     Cloth,  $3.50.    Just  ready. 

This  book  thoroughly  deserves  its  In  all  respects  entirely  up  todate. 

success.  Itisa  very  complete,  authen-  — Medical  Record. 

tic  and  useful  manual  of  the  micro-  The  chapter  on     examination  of 

scopical     and      chemical     methods  the  urine  is  the   most  complete  and 

which    are  employed    in   diagnosis,  advanced  thai    we   know  of  in    the 

Very  excellenl  colored    plates    illus  Kniclish  language. — Canadian  Prac- 

trate  this  work. — X<  n-  York  Medical  titioner. 
Journal. 


26     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

SIMON  (W.).  MANUAL  OF  CHEMISTRY.  A  Guide  to  Lectures 
and  Laboratory  Work  for  Beginners  in  Chemistry.  A  Text-book 
specially  adapted  for  Students  of  Pharmacy  and  Medicine.  New  (6th) 
edition.  In  one  8vo.  volume  of  536  pages,  with  46  engravings  and  8 
plates  showing  colors  of  64  tests.     Cloth,  $3.00,  net.    Just  ready. 

It  is  difficult  to  see  how  a  better  <  the  covers  of  this  book. —  The  North- 
book  could  be  constructed.     No  man    western  Lancet. 
who  devotes  himself  to  the  practice       Its  statements  are  all  clear  and  its 
of  medicine  need  know  more  about !  teachings    are  practical. —  Virginia 
chemistry  than  is  contained  between  j  lied.  Monthly. 

SL.ADE  (D.  D.).  DIPHTHERIA;  ITS  NATURE  AND  TREAT- 
MENT. Second  edition.  In  one  royal  12mo.  vol.,  158  pp.   Cloth,  $1.25. 


SMITH  (EDWARD). 

DIABLE  STAGES. 


CONSUMPTION;  ITS  EARLY  AND  REME- 
In  one  8vo.  volume  of  253  pp.     Cloth,  $2.25. 


SMITH  (J.  LEWIS).  A  TREATISE  ON  THE  DISEASES  OF  IN- 
FANCY AND  CHILDHOOD.  Eighth  edition,  thoroughly  revised 
and  rewritten  and  much  enlarged.  In  one  large  8vo.  volume  of  983 
pages,  with  273  engravings  and  4  full-page  plates.  Cloth,  $4.50; 
leather,  $5.50. 


The  most  complete  and  satisfac- 
tory text-book  with  which  we  are 
acquainted. — American  Gynecologi- 
cal and  Obstetrical  Journal. 

It  truly  is  the  most  evenly  bal- 
anced, clear  in  description  and 
thorough  in  detail  of  any  of  the 
books  published  in  this  country  on 
this  subject. — Medical  Fortnightly. 

A  treatise  which  in  every  respect 


can  more  than  hold  its  own  against 
any  other  work  treating  of  the  same 
subj  ect. — American  Medico-Surgical 
Bulletin. 

A  safe  guide  for  students  and  phy- 
sicians.— The  Am.  Jour,  of  Obstetrics. 

For  years  the  leading  text-book  on 
children's  diseases  in  America. — 
Chicago  Medical  Recorder. 


SMITH  (STEPHEN).  OPERATIVE  SURGERY.  Second  and  thor- 
oughly revised  edition.  In  one  octavo  volume  of  892  pages,  with 
1005  engravings.     Cloth,  $4  ;  leather,  $5. 


dium  for  the  modern  surgeon. — Be 
ton  Medical  and  Surgical  Journal. 


One  of  the  most  satisfactory  works 
on  modern  operative  surgery  yet 
published.     The  book  is  a  compen- 

SOLLY  (S.  EDWIN).  A  HANDBOOK  OF  MEDICAL  CLIMA- 
TOLOGY. In  one  handsome  octavo  volume  of  462  pages,  with  en- 
gravings and  11  full-page  plates,  5  of  which  are  in  colors.  Cloth,  $4.00. 
Just  ready. 


A  clear  and  lucid  summary  of 
what  is  known  of  climate  in  relation 
to  its  influence  upon  human  beings. 
— The  Therapeutic  Gazette. 

The  book  is  admirably  planned, 
clearly  written,and  the  author  speaks 
from  an  experience  of  thirty  years  as 


an  accurate  observer  and  practical 
therapeutist. — Maryland  Med.  Jour. 
Every  practitioner  of  medicine 
should  possess  himself  of  a  copy  and 
study  it,  and  we  are  sure  he  will 
never  regret  it. — St.  Louis  Medical 
and  Surgical  Journal. 


STDLLE  (ALFRED).  CHOLERA;  ITS  ORIGIN,  HISTORY,  CAUS- 
ATION, SYMPTOMS,  LESIONS,  PREVENTION  AND  TREAT- 
MENT. In  one  12mo.  volume  of  163  pages,  with  a  chart  showing 
routes  of  previous  epidemics.     Cloth,  $1.25. 

THERAPEUTICS   AND    MATERIA    MEDICA.      Fourth   and 

revised  edition.      In  two   octavo   volumes,  containing    1936    pages. 
Cloth,  $10;  leather,  $12. 


Lea  Beothees  &  Co.,  Philadelphia  and  New  Yoek.     27 

STELIiE   (ALFRED),   MAISCH    (JOHN   M.)    AND    CASPARI 

(CHAS.  JR.).     THE  NATIONAL  DISPENSATORY:  Containing 
the  Natural  History,  Chemistry,  Pharmacy,   Actions  ami   Uses  of 
Medicines,  including  those  recognized  in  the  latest  Pharmacopoeias  of 
the  United  States,  Great  Britain  and  Germany,  with  numerous  refer- 
ences to  the  French   Codex.     Fifth  edition,  revised  and  enlarged, 
including  the  new  U.  S.  Pharmacopoeia,  Seventh  Decennial  Eevision. 
With  Supplement  containing  the  new  edition  of  the  National  Formu- 
lary.   In  one  magnificent  imperial  octavo  volume  of  about  2025  pages, 
with  320  engravings.    Cloth,  $7.25;  leather,  f 8.  With  ready  reference 
Thumb-letter  Index.     Cloth,  $7.75  ;  leather,  $8.50. 
Recommended  most  highly  for  the    amount  of  information  contained  in 
physician,    and    invaluable    to  the    this  work  is  made  available  is  indi- 
druggist. — Therapeutic  Gazette.  cated  by  the  twenty-five  thousand 

It  is  the  official  guide  for  the  Med-  references  in  the  two  indexes. — Ves- 
ical and  Pharmaceutical  professions,  ton  Medical  and  Surgical  Journal. 
— Buffalo  Med.  and  Bur.  Jour.  Should  be  recognized  as  a  national 

The  readiness  with  which  the  vast    standard. — North  Am.  Practitioner. 

STTMSON  (LEWIS  A.).  A  MANUAL  OF  OPERATIVE  SURGERY. 
New  (3d)  edition.  In  one  royal  12mo.  volume  of  614  pages,  with  306 
engravings.     Cloth,  $3.75. 


A  useful  and  practical  guide  for 
all  students  and  practitioners. — Am. 
Journal  of  the  Medical  Sciences. 


The  book  is  worth  the  price  for  the 
illustrations  alone. —  Ohio  Medical 
Journal. 


STIMSON  (LEWIS  A.).      A  TREATISE  ON  FRACTURES    AND 

DISLOCATIONS.   In  one  handsome   octavo  volume    of  831  pages, 

with  326  engravings  and  20  plates.     Just  ready.     Cloth,  $5.00,  net; 

leather,  $6.00,  net. 

Preeminently   the    authoritative  j      Taken  as  a  whole,  the  work  is  the 

text-book  upon  the   subject.      The  ;  best  one    in    English     to-day. — St. 

vast  experience  of  the  author  gives    Louis  Medical  and  Surgical  Journal. 

to  his  conclusions  an  unimpeachable        Pointed,  practical,  comprehensive, 

value.     The  work   is  profusely   il-    exhaustive,  authoritative,  well  writ- 

lustrated.     It  will  be   found  indis-    ten    and    well     arranged. — Denver 

pensable  to  the  student  and  the  prac-    Medical  Times. 

titioner   alike. — The  Medical  Age. 

STUDENT'S  QUIZ  SERD3S.  Thirteen  volumes,  convenient,  author- 
itative, well  illustrated,  handsomely  bound  in  cloth.  1.  Anatomy 
(double  number);  2.  Physiology;  3.  Chemistry  and  Physics ;  4.  Histol- 
ogy, Pathology,  and  Bacteriology;  5.  Materia  Medica  and  Thera- 
peutics ;  6.  Practice  of  Medicine ;  7.  Surgery  (double  number);  8.  Genito- 
urinary and  Venereal  Diseases ;  9.  Diseases  of  the  Skin;  10.  Diseases 
of  the  Eye,  Ear,  Throat  and  Nose;  11.  Obstetrics  ;  12.  Gynecology  ; 
13.  Diseases  of  Children.  Price,  $1  each,  except  Nos.  1  and  7, 
Anatomy  and  Surgery,  which  being  double  numbers  are  priced  at 
$1.75  each.     Full  specimen  circular  on  application  to  publishers. 

STUDENT'S  SERIES  OP  3IANUALS.  12mos.  of  from  300-540 
pages,  profusely  illustrated,  and  bound  in  red  limp  cloth.  11  EEMAN'8 
First  Lines  in  Midwifery,  $1.25;  Luff's  Manual  of  Chemistry,  $2 ; 
BEtTCE'S  Materia  Medica  and  Therapeutics  sixth  edition),  $1.50.  net. 
BELL'S  Comparative  Anatomy  and  Physiology,  $2;  EtOBEET 
sun's  Physiological  Physics,  $2;  Gould's  Surgical  Diagnosis,  $2; 
Klein's  Elements  of  Histology  (5th  edition),  $2.00,  net  :  l'i .rri  B'e 
Surgical  Pathology,  $2 :  Tklvks'  Surgical  Applied  Anatomy,  $2; 
Ralfe's  Clinical  Chemistry,  $1.50;  and  Claeke  and  Lo<  k.wood'8 
Dissector's  Manual,  $1.50.  The  following  i.s  in  press:  PEPPEB'S 
Forensic  Medicine. 
For  separate  notices,  see  under  various  author's  names. 


28     Lba  Bbothebs  A  Co.,  Philadelphia  and  New  Yobk. 

STURGES  (OCTAVIUS).  AN  INTRODUCTION  TO  THE  STUDY 
OF  CLINICAL  MEDICINE.     In  one  12mo.  volume.     Cloth,  $1.25. 

SUTTON  (JOHN  BLAND).  SURGICAL  DISEASES  OF  THE 
OVARIES  AND  FALLOPIAN  TUBES.  Including  Abdominal 
Pregnancy.  In  one  12mo.  volume  of  513  pages,  with  119  engravings 
and  5  colored  plates.     Cloth,  $3. 

TAIT  (LAWSON).  DISEASES  OF  WOMEN  AND  ABDOMINAL 
SURGERY.  In  two  handsome  octavo  volumes.  Vol.  I.  contains  546 
pages  and  3  plates.    Cloth,  $3. 

TANNER  (THOMAS  HAWKES)  ON  THE  SIGNS  AND  DIS- 
EASES OF  PREGNANCY.  From  the  second  English  edition.  In 
one  octavo  volume  of  490  pages,  with  4  colored  plates  and  16  engrav- 
ings.    Cloth,  $4.25. 


TAYLOR  (ALFRED  S.).  MEDICAL  JURISPRUDENCE.  New 
American  from  the  twelfth  English  edition,  specially  revised  by  Clark 
Bell,  Esq.,  of  the  N.  Y.  Bar.  In  one  8vo.  vol.  of  831  pages,  with  54 
engrs.  and  8  full-page  plates.     Cloth,  $4.50;  leather,  $5.50.  Just  ready. 


To  the  student,  as  to  the  physician, 
we  would  say,  get  Taylor  first,  and 
then  add  as  means  and  inclination 
enable  you. — American  Practitioner 
and  News. 

It  is  the  authority  accepted  as 
final  by  the  courts  of  all  English- 
speaking  countries.  This  is  the  im- 
portant consideration  for  medical 
men,  since  in  the  event  of  their 
being  summoned  as  experts  or  wit- 


nesses, it  strongly  behooves  them  to 
be  prepared  according  to  the  princi- 
ples and  practice  everywhere  ac- 
cepted. The  work  will  be  found  to 
be  thorough,  authoritative  and 
modern. — Albany  Law  Journal. 

Probably  the  best  work  on  the 
subject  written  in  the  English  lan- 
guage. The  work  has  been  thor- 
oughly revised  and  is  up  to  date. — 
Pacific  Medical  Journal. 


—  ON  POISONS  IN  RELATION  TO  MEDICINE  AND  MEDI- 
CAL JURISPRUDENCE.  Third  American  from  the  third  London 
edition.  In  one  octavo  volume  of  788  pages,  with  104  illustrations. 
Cloth,  $5.50 ;  leather,  $6.50. 


TAYLOR  (ROBERT  W.).      THE    PATHOLOGY  AND   TREAT- 
MENT OF  VENEREAL  DISEASES.    New  (2d)  edition.    In  one 
very  handsome  octavo  volume  of  about  700  pages,  with  about  200  en- 
gravings and  6  colored  plates.    In  press. 
Notices  of  previous  edition  are  appended. 

diseases  that  has  in  recent  years  ap- 
peared in  English. — American  Jour- 


By  long  odds  the  best  work  on 
venereal  diseases. — Louisville  Medi- 
cal Monthly. 

In  the  observation  and  treatment 
of  venereal  diseases  his  experience 
has  been  greater  probably  than  that 
of  any  other  practitioner  of  this  con- 
tinent.— New  York  Medical  Journal. 

The  clearest,  most  unbiased  and 
ably  presented  treatise  as  yet  pub- 
lished on  this  vast  subject. — The 
Medical  News. 

Decidedly  the  most  important  and 
authoritative  treatise    on    venereal 


nal  of  the  Medical  Sciences. 

It  is  a  veritable  storehouse  of  our 
knowledge  of  the  venereal  diseases. 
It  is  commended  as  a  conservative, 
practical,  full  exposition  of  the 
greatest  value. — Chicago  Clinical 
Review. 

The  best  work  on  venereal  dis- 
eases in  the  English  language.  It 
is  certainly  above  everything  of  the 
kind. — The  St.  Louis  Medical  and 
Surgical  Journal. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     29 

TAYLOR  (ROBERT  W.).     A  PRACTICAL  TREATISE  ON  SEX- 
UAL   DISORDERS   IN   THE   MALE  AND   FEMALE.    In    one 

8vo.  vol.  of  448  pp.,  with  73  engravings  and  8  colored  plates.    Cloth, 
$3.    Net. 


the  female  is  presented  in  an  exhaus- 
tive manner,  all  of  the  causes  pro- 
ducing it  being  described.  The 
author  has  presented  to  the  profes- 
sion the  ablest  and  most  scientific 
work  as  yet  published  on  sexual 
disorders,  and  one  which ,  if  carefully 
followed,  will  be  of  unlimited  value 
to  both  physician  and  patient. — 
Medical  Nexus. 


It  is  a  timely  boon  to  the  medical 
profession  that  an  observer  of  Dr. 
Taylor's  skill  and  experience  has 
written  a  work  on  this  hitherto 
neglected  and  little  understood  class 
of  diseases  which  places  them  on  a 
scientific  basis  and  renders  them  so 
clear  that  the  physician  who  reads 
its  pages  can  treat  this  class  of 
patients  intelligently.     Sterility  in 

A  CLINICAL  ATLAS  OF  VENEREAL  AND  SKIN  DISEASES. 

Including  Diagnosis,  Prognosis  and  Treatment.  In  eight  large  folio 
parts,  measuring  14  x  18  inches,  and  comprising  213  beautiful  figures 
on  58  full-page  chromo-lithographic  plates,  85  fine  engravings  and  425 
pages  of  text.  Complete  work  now  ready.  Price  per  part,  sewed  in 
heavy  embossed  paper,  $2.50.  Bound  in  one  volume,  half  Russia, 
$27 ;  half  Turkey  Morocco,  $28.  For  sale  by  subscription  only.  Address 
the  publishers.    Specimen  plates  by  mail  on  receipt  of  ten  cents. 

TAYLOR  (SEYMOUR).  INDEX  OF  MEDICINE.  A  Manual  for 
the  use  of  Senior  Students  and  others.  In  one  large  12mo.  volume  of 
802  pages.    Cloth,  $3.75. 

THOMAS  (T.  GAELIiARD)  AND  MUNDE  (PAUL  P.).  A  PRAC 
TICAL  TREATISE  ON  THE  DISEASES  OF  WOMEN.  Sixth 
edition,  thoroughly  revised  by  Paul  F.  MundE,  M.  D.  In  one 
large  and  handsome  octavo  volume  of  824  pages,  with  347  engravings. 
Cloth,  $5 ;  leather,  " 


The  best  practical  treatise  on  the 
subject  in  the  English  language. 
It  will  be  of  especial  value  to  the 
general  practitioner  as  well  as  to  the 
specialist.  The  illustrations  are  very 
satisfactory.  Many  of  them  are  new 
and  are  particularly  clear  and  attrac- 
tive.— Boston  Med .  and  Sur.  Jour. 


This  work,  which  has  already  gone 
through  five  large  editions,  and  has 
been  translated  into  French,  Ger- 
man, Spanish  and  Italian,  is  the 
most  practical  and  at  the  same  time 
the  most  complete  treatise  upon  the 
subject. — The  Archives  of  Gynecol- 
ogy, Obstetrics  and  Pediatrics. 


THOMPSON  (SIR  HENRY).  CLINICAL  LECTURES  ON  DIS- 
EASES OF  THE  URINARY  ORGANS.  Second  and  revised  edi- 
tion.   In  one  octavo  vol.  of  203  pp.,  with  25  engravings.    Cloth,  $2.25. 

THE    PATHOLOGY   AND   TREATMENT   OF   STRICTURE 

OF  THE  URETHRA  AND  URINARY  FISTULA.  From  the 
third  English  edition.  In  one  octavo  volume  of  359  pages,  with  47 
engravings  and  3  lithographic  plates.     Cloth,  $3.50. 

THOMSON  (JOHN).  DISEASES  OF  CHILDREN.  In  one  crown 
octavo  volume  of  350  pages,  with  52  illus.  Cloth,  $1.75,  net.  Just  ready. 

TODD  (ROBERT  BENTLEY).  CLINICAL  LECTURES  ON  CER- 
TAIN ACUTE  DISEASES.    In  one  8vo.  vol.  of  320  pp.,  cloth,  $2.50. 

TREVES  (FREDERICK).  OPERATIVE  SURGERY.  In  two 
8vo.  vols,  containing  1550  pp.,  with  422  illus.     Cloth,  $9 ;  leath.,  $11. 

A  SYSTEM  OF  SURGERY.     In   Contributions  by  Twenty-five 

English  Surgeons.  In  two  large  octavo  volumes.  Vol.  I.,  1178  pages, 
with  463  engravings  and  2  colored  plates.  Vol.  II.,  1120  pages,  with 
487  engravings  and  2  colored  plates.     Complete  work,  cloth,  $10.00. 


30    Lea  Beothees  &  Co.,  Philadelphia  and  New  Yoek. 

TREVES  (FREDERICK).  SURGICAL  APPLIED  ANATOMY.  In 
one  12mo.  volume  of  540  pages,  with  61  engravings.  Cloth,  $2.  See 
Student's  Series  of  Manuals,  page  27. 

TUTTLE  (GEORGE  M.).  A  POCKET  TEXT-BOOK  OF  DISEASES 
OF  CHILDREN.  In  one  handsome  12mo.  volume  of  about  300  pages, 
with  many  illustrations.  Cloth,  $1.50,  net.  Shortly.  Lea's  Series  of 
Pocket  Text-hooks,  edited  by  Been  B.  Gallaudet,  M.  D.     See  p  18. 


VAUGHAN    (VICTOR    C.)    AND    NOVY    (FREDERICK    G.). 

PTOMAINS,  LEUCOMAINS,  TOXINS  AND  ANTITOXINS, 
or  the  Chemical  Factors  in  the  Causation  of  Disease.  New  (3d)  edition. 
In  one  12mo.  volume  of  603  pages.     Cloth,  $3. 


The  work  has  been  brought  down 
to  date,  and  will  be  found  entirely 
satisfactory. — Journal  of  the  Ameri- 
can Medical  Association. 

The  most  exhaustive  and  most  re- 
cent presentation  of  the  subject.— 
American  Jour,  of  the  Med.  Sciences. 


The  present  edition  has  been  not 
only  thoroughly  revised  throughout 
but  also  greatly  enlarged,  ample 
consideration  being  given  to  the  new 
subjects  of  toxins  and  antitoxins. — 
Tri-State  Medical  Journal. 


VISITING  LIST.  THE  MEDICAL  NEWS  VISITING  LIST  for  1899. 
Four  styles :  Weekly  (dated  for  30  patients);  Monthly  (undated  for 
120  patients  per  month) ;  Perpetual  (undated  for  30  patients  each 
week);  and  Perpetual  (undated  for  60  patients  each  week).  The  60- 
patient  book  consists  of  256  pages  of  assorted  blanks.  The  first  three 
styles  contain  32  pages  of  important  data,  thoroughly  revised,  and 
160  pages  of  assorted  blanks.  Each  in  one  volume,  price,  $1.25. 
With  thumb-letter  index  for  quick  use,  25  cents  extra.  Special  rates 
to  advance-paying  subscribers  to  The  Medical  News  or  The 
Ameeican  Jotjenal  of  the  Medical  Sciences,  or  both.  See  p.  32. 

WATSON  (THOMAS).  LECTURES  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  PHYSIC.  A  new  American  from  the  fifth  and 
enlarged  English  edition,  with  additions  by  H.  Haetshoene,  M.  D. 
In  two  large  8vo.  vols,  of  1840  pp.,  with  190  cuts.  Cloth,  $9 ;  leather,  $11. 


WEST  (CHARLES).  LECTURES  ON  THE  DISEASES  PECULIAR 
TO  WOMEN.  Third  American  from  the  third  English  edition.  In 
one  octavo  volume  of  543  pages.    Cloth,  $3.75 ;  leather,  $4.75. 

ON  SOME  DISORDERS  OF  THE   NERVOUS  SYSTEM  IN 

CHILDHOOD.    In  one  small  12mo.  volume  of  127  pages.    Cloth,  $1. 


WHARTON  (HENRY  R.).     MINOR  SURGERY  AND  BANDAG- 
ING.    New  (4th)  edition.     In  one  12mo.  vol.  of  about  600  pages,  with 
about  500  engravings,  many  of  which  are  photographic.    Shortly. 
Notices  of  previous  edition  are  appended. 


We  know  of  no  book  which  more 
thoroughly  or  more  satisfactorily 
covers  the  ground  of  Minor  Surgery 
and  Bandaging. — Brooklyn  Medical 
Journal. 

Well  written,  conveniently  ar- 
ranged and  amply  illustrated.  It 
covers  the  field  so  fully  as  to  render 
it  a  valuable  text-book,  as  well  as  a 


work  of  ready  reference  for  sur- 
geons.— North  Amer.  Practitioner. 
The  part  devoted  to  bandaging  is 
perhaps  the  best  exposition  of  the 
subject  in  the  English  language.  It 
can  be  highly  commended  to  the 
student,  the  practitioner  and  the 
specialist. — The  Chicago  Medical 
Recorder. 


Lea  Beothees  &  Co.,  Philadelphia  and  New  Yobk.     31 

WHITLA  (WILLIAM).  DICTIONARY  OF  TREATMENT,  OR 
THERAPEUTIC  INDEX.  Including  Medical  and  Surgical  Thera- 
peutics.   In  one  square  octavo  volume  of  917  pages.     Cloth,  $4. 

WILLIAMS  (DAWSON).  THE  MEDICAL  DISEASES  OF  CHIL- 
DREN. In  one  12nio.  volume  of  629  pages,  with  18  illustrations. 
Just  ready.     Cloth,  $2.50,  net. 

The  descriptions  of  symptoms  are  j  diagnoses,  prognosis^  complications, 
full,  and  the  treatment  recommended  |  and  treatment.  The  work  is  up  to 
will  meet  general  approval.  Under  I  date  in  every  sense. —  The  Charlotte 
each  disease  are  given  the  symptoms,  I  Medical  Journal. 

WILSON  (ERASMUS).    A    SYSTEM    OF    HUMAN    ANATOMY. 

A  new  and  revised  American  from  the  last  English  edition.  Illustrated 
with  397  engravings.  In  one  octavo  volume  of  616  pages.  Cloth,  $4 ; 
leather,  $5. 

THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE.    In 


one  12mo.  volume.     Cloth,  $3.50. 

WTNCKEL  ON  PATHOLOGY  AND  TREATMENT  OF  CHILDBED. 
Translated  by  James  R.  Chadwick,  A.  M.,  M.  D.  With  additions 
by  the  Author.    In  one  octavo  volume  of  484  pages.     Cloth,  $4. 

WOHLER'S  OUTLINES  OF  ORGANIC  CHEMISTRY.  Translated 
from  the  eighth  German  edition,  by  Ira  Remsen,  M.  D.  In  one 
12mo.  volume  of  550  pages.     Cloth,  $3. 

YEAR-BOOK  OF  TREATMENT  FOR  1892,  1  893,  1896,1897  and  1898. 
Critical  Reviews  for  Practitioners  of  Medicine  and  Surgery.  In  con- 
tributions by  25  well-known  medical  writers.  1 2mos.,  about  500  pages 
each.  Cloth,  $1.50.  In  combination  with  The  Medical  News  and 
The  American  Journal  of  the  Medical  Sciences,  75  cents. 

YEO  (I.  BURNEY).  FOOD  IN  HEALTH  AND  DISEASE.  New 
(2d)  edition.  In  one  12mo.  volume  of  592  pages,  with  4  engravings. 
Cloth,  $2.50.     See  Series  of  Clinical  Manuals,  page  26. 

We  doubt  whether  any  book  on    work  of  Dr.   Yeo's.    The  value  of 


dietetics  has  been  of  greater  or  more 
widespread  usefulness  than  has  this 
much-cjuoted     and    much-consulted 


the  work  is  not  to  be  overestimated. 
■New  York  Medical  Journal. 


A   MANUAL   OF   MEDICAL   TREATMENT,  OR  CLINICAL 

THERAPEUTICS.  Two  volumes  containing  1275  pages.  Cloth,  $5.50. 

YOUNG  ( J  AMES  K.).     ORTHOPEDIC  SURGERY.     In    one    8vo. 
volume  of  475  pages,  with  286  illustrations.    Cloth,  $4;  leather,  $5. 

In  studying  the  different  chapters,  surgical   specialty  and  every   page 

one  is  impressed   with  the  thorough  abounds    with    >•'■-  d                  prac- 

ness  of  the  work.    The  illustrations    ticality.     [t  is  the  clearest  and  i 

are  numerous— the  book  thoroughly  modern  work  upon  this  grow  ing  de- 

practical— Medical  News.  partmenf                         The  Ch 

It  is  a   thorough,  a   very  compre-  Clinical  Review, 
bensive  work   upon   this  Legitim 


PERIODICALS. 


PROGRESSIVE   MEDICINE. 


A  Quarterly  Digest  of  New  Methods,  Discoveries,  and  Improvement): 
in  the  Medical  and  Surgical  Sciences  by  Eminent  Authorities.  Edited  by 
Dr.  Hobart  Amory  Hare.  In  four  abundantly  illustrated,  cloth  bound, 
octavo  volumes,  of  400-500  pages  each,  issued  quarterly,  commencing 
March  1st,  1899.     Per  annum  (4  volumes),  $10.00  delivered. 


THE  MEDICAL  NEWS. 

Weekly,  $1.00  per  Annum. 

Each  number  contains  32  quarto  pages,  abundantly  illustrated. 


crisp,  fresh  weekly  professional  newspaper. 


THE  AMERICAN  JOURNAL  OP  THE  MEDICAL  SCIENCES. 

Monthly,  $4.00  Per  Annum. 

Each  issue  contains  128  octavo  pages,  fully  illustrated.     The  most 
advanced  and  enterprising  American  exponent  of  scientific  medicine. 


THE   MEDICAL   NEWS   VISITING   LIST. 

Four  styles,  Weekly  (dated  for  30  patients) ;  Monthly  (undated,  for 
120  patients  per  month) ;  Perpetual  (undated,  for  30  patients  weekly  per 
year) ;  and  Perpetual  (undated,  for  60  patients  per  year).  Each  style  in 
one  wallet-shaped  book,  leather  bound,  with  pocket,  pencil  and  rubber. 
Price,  each,  $1.27.     Thumb-letter  index,  25  cents  extra. 


THE  MEDICAL  NEWS   POCKET  FORMULARY. 

Containing  1600  prescriptions  representing  the  latest  and  most  ap- 
proved methods  of  administering  remedial  agents.  Strongly  bound  in 
leather  ;  with  pocket  and  pencil.     Price,  $1.50,  net. 


COMBINATION     RATES: 


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Medical  Sciences,      ....  $   4.00  ]    a,,,-,*") 

Medical  News 4.00  }    $7.50  (  $15  00 

Progressive  Medicine  ....      10.00  J 

Medical  News  Visiting  List         .        .        .        1.25 
Medical  News  Formulary  .        .        .         1.50  net, 

In  all  $20.75  for  $16.00 

First  four  above  publications  in  combination  .      .        .        $15.75 
All  above  publications  in  combination    ....  16.00 

Other  Combinations  will   be  quoted  on  request. 
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